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Plastic Surgery Unplugged with Dr. Raghu: Episode 8

A brand new episode of Dr. Athré’s podcast, “Plastic Surgery Unplugged” is here! In this podcast series Dr. Athré shares tips, tricks, and behind-the-scenes information on the plastic surgery industry. Listen in for interviews with professionals and patients, and Dr. Athré’s own personal anecdotes from his work in the industry. 

In episode 8, Dr. Athré talks with Dr. Gregory Buford,  founder of Colorado’s BEAUTY by BUFORD, about breast augmentation, depoliticising plastic surgery, and the experience it takes to be a top surgeon in your field. 

Listen on YouTube, Apple Podcasts, Spotify, Podbean, or Google Podcasts—and don’t forget to check out our archive of episodes 1 through 7. 

Don’t forget to subscribe and share with friends and family. Here’s episode 9: “Dr. Gregory Buford: Breast Augmentations & Breast Revision Surgery” Thanks for listening!


[Audio transcription via Rev.com]

Dr. Gregory Buford:

If you have the mindset that you want everything laid out for you, you’re not going to take the hard road. No one really says, “If I can get from A to B really easy …” I mean, no one’s going to say, “I’m going to drive around this circuitous route.” But you know what? It’s a road less traveled. It’s all about the road less traveled and that’s really what makes life interesting.

Dr. Raghu Athré:

Hi, this is Dr. Raghu Athré with Athré Plastic Surgery and Med Spa here in Houston, Texas, welcoming you to another episode of Plastic Surgery Unplugged. Today, we have a special guest, Dr. Gregory Buford, a plastic surgeon from Denver, Colorado. So we have a whole list of questions that I’d love to discuss with Dr. Buford. And we shall see if we get through it or we end up going off topic as we usually do. So welcome. Come on in. Listen to our podcast and things that you’ve always wanted to know and some of our thoughts as plastic surgeons coming to you without a filter. 

Dr. Raghu Athré:

Howdy!

Dr. Gregory Buford:

How are you? Sorry, I’m a little more casual.

Dr. Raghu Athré:

Today was clinic day for me. So it comes with the territory. All right. First of all, tell everybody out there, whoever’s listening, just who you are, where your practice is and what you like to do.

Dr. Gregory Buford:

Perfect. My name is Greg Buford. I’m a board certified plastic surgeon here in Denver, Colorado. I’ve been doing this for actually just going on about 20 years as you can tell from the gray over here. I’m a nationally recognized KOL, which is a key opinion leader within the aesthetic space. So I’ve had the opportunity to speak literally across country, around the world. I’m the author of three books. What else here? I’m the founder of, not only my practice, BEAUTY by BUFORD, which is a 100% aesthetic practice focusing on breast and body procedures as well as high volume facial injectables.

Dr. Gregory Buford:

I’m also the founder of what we refer to as CATI or Core Aesthetics Training Institute. That’s a training institute for facial injectables, for VASER technology, which is ultrasonic liposuction, as well as Renuvion. So just build out a new office. When everyone was seeking coverage during COVID, I decided, “Hey, what’s the riskiest thing I could do? Let’s buy some real estate.” I figured if the world is going to come crashing down around me, what more could go wrong? If I’m going to go bankrupt, I might as well do with a couple extra of zeros of debt to my name so I-

Dr. Raghu Athré:

And go out in style, right?

Dr. Gregory Buford:

And go out in style. Exactly. So now I have a new office.

Dr. Raghu Athré:

I’m in the same boat. I hear you. I’m building out a new office with attached surgery center. It’s the biggest headache. I think I’ve gotten a few more gray hairs just from that, just from the design process. But it is what it is. I think COVID, it gave you the opportunity to focus your business in certain ways and your practice in certain ways. And then at the same note, I sent in for permits and that was several months ago and the response I get back is, “It’ll happen. We’re behind because of COVID.” It’s the standard excuse.

Dr. Gregory Buford:

You know, I feel for you. It’s crazy because with all the supply chain shortages, everything like that, I mean, building out anything right now is really a challenge. But is there really ever a good time to build anything out? No. I mean, you really have to…Actually you touched upon something I’m going to go back on is I think not that anyone wishes to have COVID or not [inaudible 00:03:57] COVID, but to go through the COVID experience. But I think in many ways, what it offered a lot of us is to reset. And it gave us a little bit of a sabbatical, whether we wanted it or not.

Dr. Gregory Buford:

During the time, we were actually shut down for about two months. I went through and literally revamped protocols, processes. I mean, I looked at my business from a completely different light. I looked at it from the light of not how can I improve the practice, but what is the new practice post-COVID look like? Because it’s all like 9-11. I mean, after 9-11, the number one question, and the same thing people are asking about COVID, “When are we going to go back to normal?” Ladies and gentlemen, we’re never going back to normal.

Dr. Raghu Athré:

Correct.

Dr. Gregory Buford:

I mean, life has changed but not all of it’s bad. I think we’ve revealed some processes that were probably very archaic. Ways that we did business before, ways that we interacted before that really did need to change. This was the big shake up. Instead of it looking at it as a shakedown, it’s a shakeup. It’s really a refiner and something that caused us, motivated us to really think about what we do and how we can revolutionize that moving forward. If you look at successful companies…I’m a big fan of business. I wrote a book on business called Beauty and the Business a few years ago, it was actually 11 years ago.

Dr. Gregory Buford:

Then I did some classes at Kellogg. Big blog for that, there’s a program. Anyone watching that’s a physician, there’s a program out there called Physician CEO. It’s a mini MBA. It is one of the best things I ever did. That made me look at my business and my practice in an entirely different manner. But fast forward to COVID, I had the time to basically sit down and say, “You know what? What am I doing? And where’s the fact in my practice? Where can I trim?” I need to maybe spend more money and become a little bit more aggressive. I really do change a lot of those things. I mean, again, tough times like those, no one wishes upon themselves but those are times of the greatest change. And that’s really where change occurs. And without change, you don’t move forward. You’re basically treading water. You’re standing still.

Dr. Raghu Athré:

There’s a saying, “When times get tough, the tough get going.” You have to figure it out, sink or swim.

Dr. Gregory Buford:

Right. That and a lot of Cheetos.

Dr. Raghu Athré:

True. What’s the one thing you love to do? You said you do a lot of breast and body work, a lot of high volume facial injectables. What is the one thing, if I said, “Hey, number one on the list”?

Dr. Gregory Buford:

I’d say probably what I’m known for. Again, I do a lot of facial injectables. I love teaching and so forth. But I think if you had to look surgical, we can talk about surgical, non-surgical. Surgery-wise, I’d say probably my number one thing that I really enjoy doing are the challenging breast cases. I do a lot of breast enhancement, I do primary [inaudible 00:07:08]. Obviously new augmentations, lift, reduction, what-have-you. But I also see a lot of patients from across the country for breast revision. Those are challenging cases. As a fellow surgeon, you know this. Those are the cases that I mean, you can read all you want, but it ain’t in the books.

Dr. Gregory Buford:

I mean, a lot of times, we’re flying by the seat of our pants thinking, “Okay, let’s see. I had a similar case to this a couple months ago and this work. Let me try this.” That’s really where you push yourself. Again, unless you’re really tested, you kind of develop a little sense of…Well, let’s just say this, consistency is nice but it doesn’t foster development, it doesn’t foster creation. It’s really when you shake it up. I’m sure you can probably remember times that you’ve been in the OR and you’re like, “What the hell?” I mean, I haven’t seen anything like this. I mean, what do I do now? That’s really where that separates the men from the boys. It really is. I mean, that’s really where you come up with new techniques, new approaches and that’s really where the creativity begins. That’s probably where I really like spending a lot of my time.

Dr. Raghu Athré:

One of the things I’m known for is revision nasal surgery. I do a lot of revision rhinoplasty. So I can relate to the revision thing. And what I think is that when you go through training, the main purpose of training is to keep you safe. It gives you guidelines of things to do that keep you safe. And your real learning happens when you start doing these cases. I think that there’s a group of people that don’t really like doing those cases, because it is challenging and you can’t guarantee 100% excellent results every single time.

Dr. Raghu Athré:

You keep aiming for it and you get closer and closer, but it’s almost the non-tangible. I think that there’s the skillsets you learn. So there’s a surgical skillset, but there is the skillset of thinking outside the box. I’d love to hear your opinion on this. I really think as time goes on, I really think that the number of people who have this outside box thinking is actually going down. I was looking at my kids the other day. You remember Legos, right?

Dr. Gregory Buford:

God, I was raised on Legos. Legos are [crosstalk 00:09:43]

Dr. Raghu Athré:

Exactly. So was I. But when we had Legos, there were no instruction manuals. You got a bucket and you had to design and build whatever was in your imagination. And you’d always have a piece missing or something that you wanted, and you had to figure it out. Today, these Lego sets are freaking amazing. They have the Titanic and they have the Taj Mahal. So people go, “My kid does Legos.” But my question is can you do the Legos with just a bucket and not with the instruction manual? I think the number of people that can do this without the instruction manual are going down. So that’s my opinion.

Dr. Gregory Buford:

You know what? It’s actually funny. I never thought of it that way. But I think that, not to bash the millennials really, I mean, that’s just way too easy, but I think you’re right though. I mean, a lot of people want a templated lifestyle. They want to know that it’s 9:00 to 5:00, it’s this, everything’s secure and so forth. Ladies and gentlemen, that’s not life. I mean, that’s at least not life is fun. I mean, life is meant to have its ups and downs, its changes, its challenges. I went to UC San Diego as an undergraduate at Revelle College. Big, big shout out to UCSD. A couple years ago, I was actually asked to give the commencement address, 2018, to Revelle College. I spoke in front of about 6,000, 7,000 people. And I talked about how change is really the best thing that can ever happen to you in life.

Dr. Gregory Buford:

I mean, it’s when you go from A to B, you pivot B to B prime, you go to B prime to C. And you make all these changes, you learn about yourself, you learn about everything around you, but most importantly, you figure out what it is you want to do. Think about companies, I mean, because we run companies. Again, back to business. Think about Amazon. Bezos did not start out creating Amazon as anything more than just the ability to sell books, and look what it is now. I mean, it’s a grocery store. It’s an online…Good Lord, I mean, when I travel internationally and I want to get crazy spice or something like that, I go on Amazon and I’m like, “Yep, it’s on there. I can get it from wherever.”

Dr. Gregory Buford:

I order my tea from Japan, my [Incha 00:12:10] tea, and I get it on Amazon. I mean, it’s crazy but it’s really about those challenges. And again, I think you really hit on a good point, is that having something templated, if you have the mindset that you want everything laid out for you, you’re not going to take the hard road. I mean, no one really says, “If I can get from A to B really easy …” I mean, no one’s going to say, “Well, I’m going to drive around this circuitous route.” But you know what? It’s a road less traveled. It’s all about the road less traveled, and that’s really what makes life interesting.

Dr. Raghu Athré:

And there’s value in it. Okay. You hit the nail. This was my dinner conversation two days ago. When you and I were kids and we had a project in school, you’d get this open-ended thing, “I want you to find out about…” God knows what. It doesn’t really matter. First of all, the vast majority of us probably did not have access to the most up-to-date encyclopedia at home. If you were upper middle class, you may have had a set of encyclopedias maybe 10 or 12 years out. That was your first starting point to get information. Anything more than that, which probably got you through about fifth or sixth grade. But after that, you had to go to the library. Mom and dad had to drop you off at the library and you go through the card catalog and the little microfiche  and all that kind of stuff.

Dr. Gregory Buford:

You realize that most of you don’t even know what a card catalog is now.

Dr. Raghu Athré:

Exactly. So you would gather all these books. You’d go through the catalog, figure out all these books, and you’d go and pull them off the shelf, and you’d get about 15 or 20 books. And then you have to go through the books to figure out what it is the information you’re getting, then you go Xerox it. I look at it as walking to the door. You want the information but you had to walk all the way around all these different points to finally get the information that you need. And there was value in that because, first of all, it taught you how to, first of all, be more direct at getting your information. That there was knowledge that you got as you wandered through these points.

Dr. Raghu Athré:

Today, I can get anything I want in one key stroke click. But the disadvantage to that is, I mean, for you and I who’ve had the luxury of doing the other way, we’re like, “Wow, this is so cool.” But we still have the idea to go get information. But if all you know is this, that journey of walking around to get there is completely lost and it’s not something that’s reproducible.

Dr. Gregory Buford:

I think I’m going to add to that because I agree with all your points. I mean, I think that’s very, very succinct in terms of how you wrap that up. It’s getting an answer. It’s learning. It’s not only getting the answer. That’s not ultimately the end point, it’s the journey. It’s creating a mindset, a problem solving mindset. The thing that I fear, I’m going to sound like a grandpa here, the good old days, you know, having to look through that and having to actually search…Like you said, I mean, I lived in the library when I was a little kid. I mean, I was the biggest nerd. That was my second home. But I mean, we didn’t have everything online. Now, like you said on the phone, it’s crazy, the amount of knowledge.

Dr. Gregory Buford:

You can be anywhere in the world, I mean, there’s very few places in the world where you don’t have some form of internet access. I mean, I’ve been down in jungles and an eco resort. Guess what? There’s internet access. And you’re sitting there accessing all this information that you would’ve never had available to you. I think, would I go back to the old days? No, of course not. I like having that readily available information. What I think though is going to be crippling to the younger generations though is, and you alluded to this and I’ve told you about this as well too, is the problem solving mindset. The ability to say, “Okay, we have these new ways to make learning easier, more facile. We can navigate quicker.”

Dr. Gregory Buford:

But, I mean, when things don’t turn out perfectly, we’re stuck because we haven’t created that mindset. Whereas someone like you and I, that we remember when we had to do those things, we’re like, “Well, okay, if this doesn’t work, then I can go back to an older way of doing things or I can navigate around. Or I’ll figure out a different solution.” But my concern now is it’s a little too easy. And again, I’m not hearkening back to get rid of electricity, get rid of all of that. You’ll hear these old people talking about that. That’s not it at all. What I think though is I think that again, you suggested this is a way of thinking. I think we need to foster these challenges. So it’s not always so easy because life in and of itself…

Dr. Gregory Buford:

You started a company. A lot of my friends are entrepreneurs. I mean, they bootstrapped their companies, small and large. I’ll tell you, one of the best things that they will tell you that happened along the way is failure. I talked about this in my commencement address as well, too. Failure, to a lot of people, signifies that you’re a loser, that you weren’t smart enough. I heard a hedge fund analyst or a venture capitalist, I’m sorry, from Silicon Valley, one of the larger, larger firms, I can’t remember which it was but years ago. One of the things that he said is in terms of investing in companies, he always looked for people that had had a company before that had failed.

Dr. Gregory Buford:

And you think, “Well, that’s stupid. You’re investing in losers.” No, you haven’t because guess what? They’ve already made those failures. They’ve already made those expensive errors and they might not make them again. So you’re actually getting someone at a better value. But the problem as a society, we look at people that have failed as failures. The classic story is Abraham Lincoln. He was a total screw up. I mean, there was so many things that he did wrong. And ultimately, he’s remembered as a beloved president. Now, was he the best president? No, he wasn’t. But there’s a lot of people, if you look at what they did in time, all we hear about is their successes.

Dr. Gregory Buford:

We don’t hear about how they fell on their face. I mean, whether it was personally or in a business manner, what-have-you. Now, I don’t think as surgeons that we want to be emphasizing to our patients how much we fail. That’s probably not a good thing. But in reality though, that is really ultimately an integral part of the learning curve. That’s a learning curve that you can’t pay for, you can’t buy, you have to experience. It’s hands-on, it’s face down, it’s tightening this nature. It’s all those kinds of things. [crosstalk 00:19:07] of complete failure. But that’s what changes you and that’s what motivates you. And that’s what ultimately drives you forward.

Dr. Raghu Athré:

So you said you really like revision breast surgery. What are some of the most common things that you see? I’m sure that there’s a lot of … I mean, I know there’s a lot of buzz right now about breast implant associated disease. That’s a big, hot button topic. What’s your thought on it overall?

Dr. Gregory Buford:

You jumped to the most controversial issue right off. I love it.

Dr. Raghu Athré:

I love to bring it.

Dr. Gregory Buford:

I mean, here’s what I would say. I’m probably going to alienate some people and befriend others. I think that the jury’s still out on that. I was reading an article, actually. What was it? It was Global Open papers. And there was a team in there that actually submitted a paper talking about BII, breast implant illness, and looking at different bacteria, they were on the shells, looking at a variety of things. I think that it needs to definitely be explored more now. Do I think it’s associated with every symptom? Sorry guys, I don’t. It’s like COVID. You have a bad day and people go, “Must be COVID.” I felt tired at the end of the day, “Must be the vaccine.” Maybe, maybe not.

Dr. Gregory Buford:

It’s the same thing with BII. I mean, I do think there’s probably, there are some people that might be genetically predisposed. We think it’s maybe associated with bio films. I think it’s a lot more complicated than we really understand. So it’s not something that we, as a society, when I say society, the Plastic Surgery Society that we should ignore. I mean, we should definitely embrace it and we should look at it in a very truthful and a very open manner. Should we accept everything that everybody says on social media? No. I mean, the internet is rife with a lot of information, it’s also full of a lot of disinformation as well, too.

Dr. Gregory Buford:

I mean, I think one of the biggest challenges that we have as physicians, I say not just plastic surgeons, but as physicians is apparently you and I never needed to go to med school because we could just Google everything. So we get patients that come in armed with information/disinformation/myths/voodoo, whatever you want to call it. I mean, and they’re very intent on showing you that they’re very educated. And I think it’s great for patients to be educated. The problem is there’s almost a challenging of the expert. One of probably the better books I’ve read in a long time is, I think it’s either called Death of the Expert, Death of Expertise. It’s about this notion that now that experts shouldn’t be looked at or shouldn’t be respected at, my opinion matters as much as you or yours, what-have-you.

Dr. Gregory Buford:

I hate to say it, that’s not true. I mean, there are experts in fields that are just that. They are experts. I don’t argue with my attorney. I mean, I may read up on some things before we’re doing a will, just so I can walk in with a little bit of ground knowledge and a little bit of background. But if I walked in, Andy would look at me and say, “All right, go sit out in the waiting room. I’m going to do all this stuff. I’ll call you when I’m done.” Same thing with my CPA, same thing with everything. Sometimes we have to recognize that the experts are there.

Dr. Gregory Buford:

Now, do we always, as experts, do we always provide the right advice? No, we don’t. Experts can fail. I mean, we’ve seen this during COVID. There was a lot of up and downs in terms of dissemination of information from CDC. I won’t even go into all that. But a lot of information that people were like, “Well, I thought science was exact.” The problem is that even experts can make mistakes and we have to recognize that. But their batting average is hopefully a hell lot better than the non-experts. I don’t even know where I was going with all that, but…

Dr. Raghu Athré:

I agree with all that and I’m going to add a bit to it. I think it’s an evolution. So the more information you have … I think COVID was an exact, it is a great example. I think breast implant illness is also a great example. As time progresses, we also have more data points. The more data points we have, the better the experts are at giving you the correct path or the path that we should travel down. I mean, if you only have the end of two, you’re not making a hell of a lot of advice based on a limited data point. At the beginning, when the CDC says, “Hey, do this.” I mean, “Hey, that’s based on the best data that we have currently.” As this thing has evolved. I think breast implant illness is the same way.

Dr. Raghu Athré:

And to your point, I think as all of us, I mean, you and I have been in practice for several years now. This is not our first go-around at this, I think you get to a certain point where you have a certain amount of confidence where you can tell patients as well. So sometimes for example, when I put an implant in a patient, when I do a chin implant, 99.999999, everything goes great. And then there’s this one person and they have these weird symptoms and then they go, “Well, there’s another person in Alaska who had these symptoms.” Okay, great. That’s awesome. I hear you. I understand you.

Dr. Raghu Athré:

And my way of dealing with some of this is like, “Listen, I’m not saying I don’t hear you. I’m not saying you’re full of crap. But I don’t have the logical line to draw that this is what happened, this is what’s going on and this is why you have those symptoms.” That little jump is not there. So we have one of two options, you can go through the process and see if the symptoms are resolved. If you feel that that’s too much for you, we got to take it out and see if the symptoms resolve. One or the other. We got to make a decision.

Dr. Gregory Buford:

Ultimately as well, too, this is why I always tell patients, “It’s your body. It’s your body. Unless you come in and you say…” I’m sure you’ve had these patients, “I want you to put horns on my head. I want to do something crazy.” No, I will not do that.

Dr. Raghu Athré:

I had one that wanted implanted whiskers.

Dr. Gregory Buford:

Did you?

Dr. Raghu Athré:

He actually wanted implanted whiskers. He wanted to look like her cat.

Dr. Gregory Buford:

I’ll know now who to refer all my crazy ones to, so I’ll get your…I think it’s about having a thoughtful discussion and being open to that. But as you pointed out though, too, you’ve got to have enough information. But I think what ASPS is doing right now I think is the mindful approach. They’re saying, “Look, we’re not ignoring you. We’re accepting this but we’re going to do it in a fact-based way. We’re going to take the emotions out of it.” But like I said, I tell patients, “If you think that taking your implants out is going to make you feel better…” I mean, it may or may not. I understand that it may not. What gets me though is there’s a lot of procedures. I mean, a good example is the en bloc. The en bloc, there’s not a single paper in the literature, anybody who’s watching right now, I challenge you, find a single, thoughtful, scientific peer-reviewed paper that actually shows efficacy. I mean, there’s none.

Dr. Raghu Athré:

There’s zero.

Dr. Gregory Buford:

There’s zero. The problem is people are coming in and they’re getting the procedure, not realizing that there’s a lot of risk. Now, if you’re above the muscle, you’ve got more buffer, you can do an en bloc and there’s not as much risk. If you’re below the muscle, what’s on that back part is your rib cage. Those of us who have been in that area and we’ve dissected, that’s a very thin area. What happens is if you get into that muscle, which I can tell you having done a ton of capsular revisions, in the thousands, I can tell you, it’s very easy to do that. I mean, thankfully I’ve had dropped one lung in my career, just one. But I mean, it’s only a matter-

Dr. Raghu Athré:

It’s the anatomy that’s there and it’s not that far away.

Dr. Gregory Buford:

Right. What gets me though is there’s a lot of people that are promoting it, there are a lot of people that are saying, “Well, you need to do this, you do this. The other thing is the whole mold and the implant.” Give me a break. I mean, I have taken out literally, I don’t know how many thousands of implants, both saline and silicon. Silicon, you’re not going to see mold because that’s sealed. Saline, I mean, you can see some brown in there from the really older implants, that’s betadine. That was the old days when physicians were injecting betaine internally with the saline thinking that if you had a little bit of extrusion of the fluid over time, that it was providing protection against capsular contracture. Dexamethasone and steroid was injected there as well, too. But as far as mold in there, I mean, I’ve never seen one single case of that.

Dr. Gregory Buford:

But again, getting back to BII, there’s probably is something to that, but the problem is is separating the fact from the fallacy, separating emotion from hard science. And the other thing, too, is I think we’re also a generation where we want answers immediately. We’re distraught if we don’t sit down and say, “Okay, I’m going to figure out this problem.” And 20 minutes later, we have the solution. It doesn’t work like that. You mentioned we need a large end. We need a large sample size to actually make valid conclusions. Just by saying, “Well, I had a friend of a friend who did this, therefore …” I’m sure you hear that all the time. It’s like, “I know someone…”

Dr. Raghu Athré:

But see, and this is now we’re going to get into this little … I’m going to take the first step on the ice on the lake. I’m going to take the step on the ice. Your prior point about the expert is very well taken. I think part of this also is we are in the society of political correctness where the expert doesn’t want to say, “I am the damn expert and you are wrong.” To your point, this en bloc capsulectomy, names to bring with hell to protect the innocent. I know a guy here in Houston and that’s his gig. It’s like the village drummer that comes in like, “Hear ye, hear ye, hear ye.” He makes a big noise about this.

Dr. Raghu Athré:

So everybody rushes in and he’s like, “The capsule’s part of the problem, I got to whack it all out.” And all these people are thinking they’ve done this amazing surgery taking out all the bad juju. But at the same note, the amount of deformity that’s left, because you’ve taken out a certain amount of tissue. Then a few years down the road, they go, “You know what? That doesn’t look so great.” Well, now you’re back in a bigger damn hole because there was some amount of tissue that was basically violated and removed, which there was no need to do so.

Dr. Gregory Buford:

Right. Your points are all well taken. And I think it really is tough. You hit the nail on the head. I mean, political correctness. People that know me know that I’m probably sometimes not very politically correct. But at the same time, I’m not just going to agree with someone because they have a viewpoint. There’s a lot of things that I’m not an expert and I am the first to say, “You know what? You’re right. You probably know more about it than I do.” The key thing is I think right now, people are more concerned about posturing, about making sure that their voice is heard.

Dr. Gregory Buford:

I mean, it’s great, your voice can be heard. But if you’re not saying something that’s correct, is your opinion really that valuable? Because really when it comes down to it, it’s just that then, it’s just an opinion. And there’s a lot of people over the years that have thought things because it “makes sense”. The earth is flat, this and that. It’s not true. So I do think that we need to step back a little bit. I’m not saying to be politically incorrect and I’m not saying to not listen to opposing viewpoints. But what I’m also saying though is I’m suggesting that I think that there’s value in discourse.

Dr. Gregory Buford:

And the problem is too often, and social media has become a very interesting playground and it’s become a shouting match. It’s whoever can shout the loudest. It’s not fact-based. I remember, I guess, the good old days when we actually had a dialogue, and now it’s more of a monologue. It’s basically someone getting on, shouting as loud as they want. And if you don’t agree with them, they’re not going to say, “Well, let me take that into consideration. Let’s talk about your point.” It’s, “You’re totally wrong. You’re a bad person. You must hate me,” blah, blah, blah. No. Just because I don’t agree with you doesn’t mean I hate you. Not at all.

Dr. Gregory Buford:

I have plenty of friends. I have a lot of friends with very different political viewpoints that may not agree with me. They’re still my friends. Because it doesn’t make them a bad person because they don’t agree with me on something. I think that getting away from this political correctness. In medicine, I mean, I think that’s become very, very calm. And now with the vaccines, should I or shouldn’t I? Is this a scam? Is this this? And politicized. I mean, I have to laugh.

Dr. Raghu Athré:

It is comical. It’s comical.

Dr. Gregory Buford:

The virus doesn’t care if you’re gay or straight, male or female, Black or white, Jewish, Catholic, whatever. It hates everybody. It’s an equal opportunity virus. I mean, it doesn’t know.

Dr. Raghu Athré:

[crosstalk 00:33:28] look at its contagion around the world. It’s not like there’s been a single border where it says, “Not going there.”

Dr. Gregory Buford:

Those people, I like. I mean, the virus hates everybody. The virus is kind of like Chris Rock comedy. Chris Rock pokes fun at everybody. I love Chris Rock. But that’s what the virus, virus is an equal opportunity, whatever you want to call it. I think we need to get away from politicizing that. I stirred us off track but I think what you were talking about with the breast implant illness though, that is something that’s a valid issue. But what concerns me though is the people within our own industry, as you talk about the gentleman in your town, I mean, they’re monopolizing on it. And you know what? Shame on them. I mean, it really it’s unethical. It really is.

Dr. Raghu Athré:

Correct.

Dr. Gregory Buford:

What I always tell my patients, I have a saying, “I’m not afraid to spend your money, but I’m going to spend it wisely.” So in other words, there are a lot of people that come in, I’m sure it’s the same thing in your practice, any good plastic surgeon or any good physician, for that matter, is going to have to use one of the most important words in medical language. That’s called the word no. Scott Spear taught me that. And he said, “They’re the one word that we need to learn as plastic surgeons to tell our patients, is the word no. And say, ‘We’re not going to do this for you.'” No matter what the patient’s read, if someone comes in and says, “I demand to have this procedure.” My comment is, “No, it’s not going to happen.” “Well, I pay you more.”

Dr. Gregory Buford:

It’s not about the money. It’s not about the money. It’s about our ethical responsibility. You can get highfalutin and talk about the Hippocratic Oath and all that kind of stuff. But I mean, really what it comes down to is golden rule. If someone was treating my mother, for example, or one of my family members, what would I want them to do for that family member? I do the same thing for my patients. That’s the golden rule. I mean, it’s not about me getting sued or not sued, or what-have-you. Not that I want to get sued, but after a while, you’re kind of like, “Well, it’s a numbers game.”

Dr. Gregory Buford:

It’s really at the end of the day, when it comes down to retire and to hang up my practice, so to speak, have I always looked at the best patient’s interest in mind? Have I always kept those in mind? What has been the guiding force? Ultimately, that’s the fun of it. If you can look at yourself in the mirror and say, “You know what? I’m making the right decision. They’re not based upon money, they’re not based upon fame. They’re based upon what I think is the right thing to do.” What I’ll emphasize, too, is what we think is right is not always right. Many of us have made errors, but ultimately we’ve had the patient’s best interest in mind. If you do that, then I think that’s a sign of a good physician.

Dr. Raghu Athré:

It’s called a can you sleep at night test. There’s two questions, can I sleep at night? And if I had to do it all over again with the same information, would I make the same decision? It’s the same thing you probably learned in elementary school. And it doesn’t really change that far beyond that.

Dr. Gregory Buford:

It’s funny what you just said, because it’s true. I mean, we get all these advanced degrees and so forth and really, it all comes down to the basics. Just because we have multiple degrees doesn’t mean that we … We think at a little different manner than when we didn’t have all these degrees, but ultimately what it comes down to is again, the basics. Like you said, when I do it all over again, am I looking at the patient’s best interest in mind? And can I look at myself in the mirror?

Dr. Gregory Buford:

The mirror test, I think, is critical because, ultimately there are going to be times when we make the wrong decisions, but we did it with good intent and I’m not justifying bad outcomes. I do a moderate amount of medical malpractice. What I look at when I look at cases is things happen, complications happen. The best surgeon—I always say that the only surgeons that don’t get complications are one, they don’t operate, two, they lie. That’s absolutely [crosstalk 00:37:41]

Dr. Raghu Athré:

That’s the exact same thing that I say because I have this little thing and you end up saying the same thing over and over again. I do a lot of facial rejuvenation surgery. You’re talking about a facelift, then I’m like, “Okay, here’s the anatomy. We got the facial nerve that’s here. This is the statistical risk for that and then a hematoma.” And I’m like, “Okay, this is the statistical risk and this is what the risk is in my practice. It’s not zero. And anyone telling you that the risk of a hematoma is zero, they’re either lying or haven’t done enough. One or the other.”

Dr. Gregory Buford:

Right. Everyone’s going to get complicated. Well, you don’t want to go to someone who gets a lot of complications. The other thing as well, too, is a sign of a good physician or the sign of a good person in general is when something happens, one, they can diagnose it and two, they stand behind you. I’ve had complications. Not a ton of them, but I’ve had my complications. I don’t think it gets any easier. Maybe I sleep a little bit better, but I still stay awake at night when I get that phone call, I’m like, “Shoot, I got a hematoma.”

Dr. Gregory Buford:

No one ever goes, “No big deal. I’ll just [inaudible 00:38:54] the on-call guy.” No one ever says that. When you get to that point, it’s probably best to retire and just hang it up. But, ultimately if you care, that’s the sign of a good anyone in any industry. That’s really something that when it does start faltering, that you have to reassess what your goals are. I mean, are you really in it for the right reason?

Dr. Raghu Athré:

I think those are excellent points. I have one question. Keely told me about the Boob Job Bible. Tell me about this.

Dr. Gregory Buford:

First of all, I think it’s obviously a very clever title. I would love to take responsibility for that but that was actually a team effort. So I had a number of people working on it with me. I ran around, I had a number of ideas in terms of what I wanted to call it. So we all voted and came up with Boob Job Bible. What I wanted is I like serious text, but I wanted to create a more consumer text. I wanted to create a consumer text that was friendly and that was something that a woman could look at and say, “You know what? This is really helpful. These are all the questions that I really need to know.” We have a whole list, what you should ask your plastic surgeon, what you … Pearls and pitfalls. What you should watch out for if your plastic surgeon does this? These are all the behind the scenes that a lot of people don’t know.

Dr. Gregory Buford:

What I wanted to do is prepare essentially a guidebook that was not self-absorbent or anything like that. I mean, you won’t find in there about … There’ll be a little accolade about me, but it’s really not about me. I mean, the whole book is it’s more of a tongue in cheek, a fun, playful look at breast enhancement. And something that anybody can look at and say, “You know what? I think this is great in helping me be prepared for my procedure.” I mean, you can do the same thing for facelifts. It’s a really…

Dr. Raghu Athré:

You really have a little book about it. Cool.

Dr. Gregory Buford:

I think it’s very important. I’ve had people say, “Well, you’re really good at dumbing this down.” I’m not trying to dumb it down because that’s suggesting that your patients are not as smart. It’s not that at all. Actually, what I talk about is it’s kind of cocktail talk. Think about when you’re at a cocktail party, someone asks you something about a facelift. You’re not going to say, “Well, according to this, this mass layer,” and blah, blah, blah, blah, blah. You’re not going to do that You’re going to put it in terms that they can readily understand and you’re not dumbing it down. You’re making it easier to understand for someone that doesn’t have the background. That’s what I did with Boob Job Bible. We’ve had a ton of downloads. I mean, people come in and say, “I’ve seen this book. It’s great.” We’re probably stupid because we don’t charge people for it. It’s complimentary downloads but [crosstalk 00:41:45]

Dr. Raghu Athré:

It’s on your website?

Dr. Gregory Buford:

It’s on my website, yeah.

Dr. Raghu Athré:

I’m going to put a link up here. At the end of this, I’ll tag it up and I’ll put a link up to it.

Dr. Gregory Buford:

I mean, for me, it’s a public service thing. Ultimately, I want consumers to go in and ask the right questions because the challenge in what we do…I mean, there are dentists doing facelifts. No disrespect to dentists. A lot of my friends are dentists. There are dentists doing breast augs. I mean, it’s…

Dr. Raghu Athré:

There’s a family practitioner doing breast augs. Okay?

Dr. Gregory Buford:

It scares the hell out of me. I mean, anybody watching this, too, go to someone that is well-trained and in focus. I say the other thing too is don’t go to the person that does everything. I always have to laugh when I see the rankings of plastic surgery or not the rankings, but the advertisements. You’ll see that they do 30 different things. They do all this stuff. Jack of all trades, master of none. I mean, it really is. But even worse now are the cosmetic surgeons. I mean, those just drive me crazy because they’ll say, “Well, I’m a cosmetic surgeon.” “Really? What is your background?” “I’m a cosmetic surgeon.” “Okay. That doesn’t exist. What’s your real background?” “Well, I’m an internist.”

Dr. Gregory Buford:

“Really? So that means that before you started doing breast augs, you had zero surgical training, and now suddenly you’re operating in the chest wall and you have no training.” “Well, what could go wrong?” “Well, a lot.” The problem is, is that we’re thought of, when I talk to people about that, we’re thought of as just greedy. It’s like, “Well, you just don’t want someone capitalizing on it.” No, it’s I want people that are well-trained. There are things called residency programs, fellowships that were put there for a reason. So you could actually learn with a specified goals, objectives and attain a certain degree of competency in what you’re doing.

Dr. Gregory Buford:

And getting that in a weekend course, it doesn’t happen. And when you’re looking over someone’s shoulder for three months, I mean, I love that one. “Well, I trained with Dr. So and so.” “Really? So what was your hand on?” “Nothing. But I looked over the shoulder for three months.” “Really? I’m sure that really helped you a lot.” So it really, to anyone, whether it’s a facelift, a nose, job, rhinoplasty, anything..

.

Dr. Raghu Athré:

Every specialty has their … I mean, we all go to training for a significant amount of time. I’m going to take it one step further. It’s not just the surgical procedures. I mean, even certain things like injectables. I’m a member of this group. It’s a Facebook group called the Physician Dads Group. Mostly for humor. There’s a lot of humor that goes on there but some of the stuff is, and I’m going to say this, it’s downright scary. There is a physician, again, names are being withheld, non-surgeon, who says, “I want to make more money. All my friends have meds spas. Where do I get training to inject fillers? Because I think it’s a good gig to make extra money.” I mean, he’s a gastroenterologist. There’s more and more of this. And I think part of this is that when we put out our results, when we put out our videos or whatever these things, it’s almost like we make it look too easy sometimes that everybody thinks that they can do it.

Dr. Gregory Buford:

Right. Well, I’ll go one step further to do it yourself. I mean, we’re fixing. I can’t tell you how many bads…I do a lot of injectables in my office. I have a PA and also I medically direct a number of med spas here in Denver. I can’t tell you how many people now we’re seeing on a weekly basis that have either gone to someone that’s inexperienced or they’ve done it themselves. They’ve gone vascular occlusion. I mean, all kinds of crazy stuff. We’re one step away from seeing people with blindness. People are injecting crazy stuff.

Dr. Gregory Buford:

A good example, I just posted on social media about a week or so ago about a case that we had with a HyaloPen. HyaloPen is that pen that basically injects hyaluronic acid you get off Amazon and so forth. It injects hyaluronic acid with pressure to an unknown depth. Well, what could go wrong with that? A lot. We saw someone with an occlusion on her lip. It was starting to corrode. She had gone on, and the lip was firm, as hard as a rock. It’s the craziest thing in the world. But the problem consumers are thinking, “Well, it’s an easy way to get into it.” Same thing with a lot of people wanting to get into the injection business. The first thing that I do, and I run a training institute and I make sure I vet people, in Denver, Colorado, if you have a medical director, literally, you can be the front desk person and you can inject, believe it or not.

Dr. Raghu Athré:

Same with Texas.

Dr. Gregory Buford:

Is that same thing in Texas?

Dr. Raghu Athré:

Yeah.

Dr. Gregory Buford:

It scares the hell out me. I mean, and I’ve contacted the state health board and said, “Look, you guys, I’ve been on so many high level complications panels with Allergan, with Galderma, with Merz, all these guys.” And I’m like, “I know the stuff that can happen. And it’s not that people shouldn’t be injecting. But the problem is that there needs to be some regulation in terms of who can do what.” When you know what they look at it as? They look at it as, “Well, it’s just a turf battle,” which is absolutely ludicrous. I mean, I did general surgery residency and I rotated neurosurgery. I can tell you, no time soon am I going to be opening up a neurosurgery clinic just because I spent a little time on a rotation. I wouldn’t do it. But people are opening up plastic surgery practices. And what gets me is they call in plastic surgery practice. And the media, when something happens, they go, “Plastic surgery gone wrong.” No, it’s not. It’s not plastic surgery because it wasn’t done by a plastic surgeon.

Dr. Raghu Athré:

It’s like that … Who is that? There was a very famous lady. I think she went down to Dominican Republic or something like that. Her family member and this one clinic had four fatalities within, I think, a three or four-month period. Non-board certified anesthesiologists outside the country. The list kept going on and on and on and on. And you’re right, so the thing is plastic surgery nightmare. There’s this other side that goes, “Do you know the amount of credentialing that goes through actually running a real OR and doing a credentialed OR? Triple A or quad A OR?” I mean, there’s a lot that goes into it. It’s not just a, “Hey, let’s just go operate.”

Dr. Raghu Athré:

The other day, this was about three weeks ago, I had a friend … I was operating at the surgery center and there’s only two rooms. My room and the other room that was going. And it’s a good friend of mine. He’s an excellent general surgeon. I mean, he has treated several members of my family. Have nothing but the highest regard for him doing the laparoscopic cholecystectomy. This is something that you should probably, if you’re a general surgeon, this is something you do day in, day out.

Dr. Gregory Buford:

Bread and butter.

Dr. Raghu Athré:

Bread and butter, right hand, I’m making a joke at this point for anyone out there who wants to open a general surgery clinic, you should be able to do it with your right hand tied behind your back type of thing. Appropriate patient selection. I mean, everything is above board. I finished my case and the nurse from the other room comes in and says, “Would you please go into the other room?” I’m like, that’s a question mark with a … So you walk in and he says, “I really need another set of hand. There’s no one else here. There’s only the anesthesiologist. I would really appreciate if you glove up, I need another set of hands. Hold the camera.”

Dr. Raghu Athré:

Okay. Holding the camera and I’m looking at the camera and there’s just blood. There’s just blood. And I was like, “Okay.” So your heart rate’s going up a little bit. Finally, what had happened is there was a small nick in the hepatic artery and it was a pretty uncontrolled amount of bleeding. So it ended up doing basically a laparotomy, opened it up in order to find the bleeder. And it really kind of there’s that point where you sit there at the end and you’re going through M and M and you go, “Even the bread and butter cases, there is complications and you can get those.” And this is nothing that he did incorrectly. He didn’t do anything, it’s one of those things. It’s like saying, “I’m driving a car, you’re going to get into a car accident at some point, even being the safest of drivers.” If I could leave those guys that want to open these clinics up going, “When that does happen, who are you going to call?”

Dr. Gregory Buford:

Right. I’m sure you’ve heard this very, very common statement made by anesthesiologists, “Anesthesia is 99% boredom and 1% sheer terror.” I think that’s surgery as well, too. Sometimes you get into bleeding, for example. I mean, that’s probably the scariest. And you’re like, “Okay, this is tincture tightening.” I mean, it really is. It doesn’t matter how many years you have under your belt. I think that the more years you have, you learn to kind of relax, take a deep breath, assess the situation. You put your emotions aside, you don’t panic. But surgery is surgery, and like you said, the smallest of things, I mean, filler, good example, you can go blind. You can go blind with filler. And that’s not just making it up. There’s a number of solid reports to that.

Dr. Gregory Buford:

My fear is it’s going to become more common because more and more people are doing it that really shouldn’t be doing it. I mean, that’s why I opened a training institute. I vet out who I’m training. I work with good products. I teach people. One of the most important things I teach people is we teach business and all that kind of stuff. But what we open with is anatomy. It’s all about anatomy. It’s all about knowing why you’re doing what you’re doing, where you’re doing it. And it’s really, really having a vested interest in understanding the physiology and understanding where the muscles are and all that kind of stuff. The challenges a lot of courses have, it’s all about the pattern.

Dr. Gregory Buford:

If you’re going to do Botox, you do filler. “How do I inject it?” “Well, what do you mean ‘How do I inject it?'” “I just want to know how to inject it.” The problem with that is I mean, that’s like learning to drive a straight line. Sooner or later, you’re going to have to take a right or left turn. If you just learn to hold onto the wheel, you don’t understand that. So you got to be fast and learn to think out of the box. Rounding it out to what we were talking about before is you learn for your prior experiences. You learn about the anatomy, you learn all these things.

Dr. Gregory Buford:

But unfortunately the almighty dollar has created an influx of people into the field, especially in elective surgery, because I mean, it can be lucrative. You can make a good living. The problem  is that it hasn’t always attracted the best and the brightest. It’s gorgeous. Sometimes it’s just the people that want to have a great business and this looks like a good venture to go into.

Dr. Raghu Athré:

Well, we can’t solve the world’s problems tonight.

Dr. Gregory Buford:

Maybe tomorrow.

Dr. Raghu Athré:

We have to work on it. We won’t give up though. Thank you so much for joining me.

Dr. Gregory Buford:

Well, it was an absolute pleasure. I’d love to be on again. You’ve got a great podcast and I think that was a lot of fun.