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Plastic surgery soars in popularity, but providers ask, Is that good news?’
TV, celebrities fuel interest, but publicized cases indicate risks
Celebrities, such as Today show weatherman Al Roker, tout the dramatic impact that plastic surgery has had on their lives. So-called reality television programs show people who say plastic surgery has changed their lives forever.
The public has responded with rising interest in the procedures. More than 8.7 million cosmetic plastic surgery procedures were performed in 2003, which is a 33% increase from 2002.1 The number of males having cosmetic plastic surgery procedures increased 28% from 2002 to 2003.2
"Most of the [TV] shows are anything but reality in truth, but the exposure has certainly raised public awareness of what aesthetic plastic surgery can provide," says Michael McGuire, MD, FACS, president and public education chair of the Gurnee, IL-based American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF).
However, as the numbers have grown, so has publicity about occasional poor outcomes. Two patients died at Manhattan Eye, Ear and Throat Hospital in New York City after experiencing complications during elective cosmetic procedures, according to the New York State Health Department, which investigated the cases earlier this year. One of the cases was widely publicized because it involved Olivia Goldsmith, author of the First Wives Club. After investigating the deaths, the state department of health fined the hospital $20,000 for 10 violations of standards of care, including failure to conduct basic preoperative assessments, failure to adequately monitor changes in the patients’ vital signs, and failure to effectively respond to adverse incidents.
In another media report, the Florida Center for Cosmetic Surgery in Fort Lauderdale declared bankruptcy this summer after several malpractice lawsuits, including one involving a woman who claims she went in for liposuction and lost her legs due to a punctured bowel.
However, a study documenting outcomes for more than 400,000 surgical procedures performed in accredited office-based surgery facilities by board-certified surgeons found the risk of death comparable to that of surgeries performed in hospital surgery facilities.3 The 2001-2002 data were collected by the AAAASF. Seven deaths were reported, occurring in one in 58,810 procedures (0.0017%). Six of the deaths were related to pulmonary embolism.
Many physician offices performing plastic surgery have little regulatory control, sources point out. According to the Arlington Heights, IL-based American Society of Plastic Surgeons, 56% of cosmetic procedures were performed in offices in 2003, 28% were performed in hospitals, and 16% were performed in freestanding ambulatory surgical facilities.4
More physicians who are unqualified to perform plastic surgery, including dentists, are trying to do these procedures, McGuire notes. "The reason is money. If you can’t survive doing what you were originally trained to do, you have a choice of doing something else in medicine, or you go drive a bus," he says.
There are reporting mechanisms in place for hospitals and surgery centers that experience poor outcomes, says Kathryn McGoldrick, MD, FABA, professor and chair of anesthesiology at New York Medical College and director of anesthesiology at Westchester Medical Center, both in Balhalla, NY.
"But in offices, unless the media gets wind of something gone awry, frequently serious complications are not reported," McGoldrick says, who adds that about 15 states have regulations for office-based surgery and anesthesia.
"In other states, it’s like the Wild West, because there’s little in the way of regulatory control, follow-through for complications, and other oversight," she says. "That’s very troubling."
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Patient selection is critical, says Janice Izlar, certified registered nurse anesthetist at Georgia Institute for Plastic Surgery in Savannah.
"Have an open dialogue between anesthesia providers and surgeons, to ensure the patient is assessed properly and is a good candidate for the procedures," she advises.
In general, aesthetic plastic surgery procedures are not appropriate for American Society of Anesthesiologists (ASA) Class III, IV, or V patients, McGuire says. However, some plastic surgery procedures are performed on patients with significant comorbidities, he says. "One of the major areas of growth has been post-bariatric surgery."
Secondly, the patient and the procedure must be handled by the correct type of facility, McGoldrick says. "Frequently, plastic surgery procedures can be done quite safely in an office," she says. "I think it’s up to the surgeon, anesthesiologist, and patient to ensure that they’re having the procedure done in an appropriate facility."
If someone is medically fragile, has a coexisting disease, and is having a lengthy plastic surgery procedure, then the office probably isn’t the best location, McGoldrick adds. "Patients like that will want to be done in a hospital where there are more layers of protection and backup if something goes wrong," she says.
Also, all physician offices are not created equal, McGoldrick points out. "Some have the highest caliber of anesthesia care," she says. "Others don’t even have an anesthesiologist on the premises."
Facilities should be accredited and have appropriate equipment, monitoring, and oversight for patients, sources say. For example, facilities performing plastic surgery procedures should have a defibrillator, appropriate emergency drugs, and airway equipment for an emergency in the facility, McGoldrick explains.
Proper credentialing of physicians is key, stresses McGuire. One applicant for credentials at a hospital where he is affiliated brought in a large stack of operative reports, he says.
"When you read them, you discover they didn’t actually do the procedures; they were observers or assistants on those procedures," McGuire says. "It’s not just buyer beware, but it’s facility beware."
Plastic surgeons should be certified by the Philadelphia-based American Board of Plastic Surgery, he notes.
Watch out for physicians who attend weekend courses, and are referred to as "weekend wonders," who then try to perform liposuction, face lifts, and/or breast lifts, McGuire warns. "Demand has stimulated more of these people to do something they’re not qualified to do," he says. "The facility is assuming liability for credentialing them if an individual is not adequately trained."
The anesthesia provider is critically important, says Ronald Iverson, MD, FACS, chair of the Patient Safety Workgroup for the American Society of Plastic Surgeons and administrator of The Plastic Surgery Center in Pleasanton, CA. "Many deaths in ambulatory surgery are related to anesthesia care, not surgical care," he points out.
Reality shows are unrealistic about what can be done in a typical surgery center, Iverson says. "Patients haven’t paid attention to the fact that, in addition to plastic surgery, they’re getting new teeth, new makeup, and spending six to eight weeks in an intense program to get the maximum out of the plastic surgery segment of the extreme makeover," he says. Also, patients often don’t understand what can be done safely in an outpatient surgery center vs. a major hospital, Iverson adds.
McGuire also expresses unease. "I’m concerned about reality shows trivializing aesthetic surgery, make it seem as if it’s the same thing as getting your hair done or your teeth capped," he says. "It’s real surgery, with real risks, and real anesthesia which has risks."
On the reality shows, plastic surgery often is performed without necessity, McGuire says. "It gives the image that everything in life is dependent on the shape of your nose, and all of your problems are related to the fact that you had big hips," he says.
These portrayals leave physicians with the burden to offer a very thorough informed consent, McGoldrick says.
The physician needs to communicate to the patient that there’s no such thing as a totally risk-free procedure, she says. "You have to make sure the patient has a very deep understanding of the potential complications," McGoldrick says.
Also, the physician needs to ensure that the patient has realistic expectations, she says.
"The physician has to make the person realize that plastic surgery isn’t a panacea for whatever is bothering them in life," McGoldrick says. "If they come out of procedure more attractive, perhaps it won’t affect their life or their happiness."
1. American Society of Plastic Surgeons. 2003 Quick Facts — Cosmetic and Reconstructive Plastic Surgery. Arlington Heights, IL; 2003. Web: www.plasticsurgery.org/public_education/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=13619.
2. American Society of Plastic Surgeons. 2003 Gender Distribution — Cosmetic Procedures. Arlington Heights, IL; 2003. Web: www.plasticsurgery.org/public_education/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=13620.
3. Keyes GR, Singer R, Iverson RE, et al. Analysis of outpatient surgery center safety using an Internet-based quality improvement and peer review program. Plast Reconstr Surg 2004; 113:1,760-1,770.
4. American Society of Plastic Surgeons. 2003 Cosmetic Demographics/Post-Bariatric Procedure. Arlington Heights, IL; 2003. Web: www.plasticsurgery.org/public_education/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=13323.
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