Plastic Surgery Proliferation

Plastic Surgery Proliferation
Demand for Aesthetic Surgery is a Boon for Ambulatory Care

By Kelly M. Pyrek

Cristina Jeusch

Agrowing acceptance of plastic surgery is accelerating demand for aesthetic and reconstructive surgical services. With more procedures suitable to the ambulatory surgery center (ASC) environment, this is one area in which medical entrepreneurs and surgeons are capitalizing.

“Plastic surgery is not taboo anymore, and I think it’s no longer perceived as something only for the rich,” says Boca Raton, Fla.-based plastic surgeon Cristina A. Keusch, MD, PA, FACS. “With improved techniques and anesthesia, and with outpatient centers that allow us to do this in a more cost-effective way, plastic surgery is something that has become more affordable over the years. Cosmetic surgery is not something people are embarrassed about anymore, and it’s not so hush-hush. I think all of these factors contribute to the increase in plastic surgery cases.”

Nearly 6.9 million cosmetic surgical and non-surgical procedures were performed in the United States in 2002, according to the American Society for Aesthetic Plastic Surgery (ASAPS).

Compared to 2001, surgical procedures increased 1 percent (to 1.6 million), while non-surgical procedures declined 23 percent (to 5.3 million). ASAPS reports the overall number of cosmetic procedures has increased 228 percent since 1997.

“Last year’s increase in surgical procedures, while small, speaks to people’s strong motivation for making positive changes in their lives — despite worries about the economy and world tensions,” says Franklin DiSpaltro of ASAPS.

Among the most significant increases in the surgical category for 2002, compared to the previous year, were abdominoplasty, up 17 percent; breast augmentation, up 15 percent; breast reduction, up 9 percent; facelift, up 6 percent; and breast lift, up 4 percent.

News reports of back-alley butcheries, surgeries performed in vans, dirty instruments and filthy surgical environments have been fueling the fires of healthcare consumer fears and media frenzies. Reports of phony doctors being arrested after their surgeries cause disfigurements and deaths have created lingering stereotypes that legitimate physicians combat daily.

“Most cosmetic procedures have excellent safety records, so people may be easily persuaded that they are simple to perform and are without risk,”

DiSpaltro says. “But in the hands of untrained physicians or possibly criminals posing as doctors, the results can be disastrous.”

Performing surgery in Florida — a hotbed of plastic surgery activity and regulatory/ licensing conflict — can be challenging, Keusch says, but she believes a more positive focus by the mainstream media has helped. “And thankfully,” she adds, “the majority of us are practicing safe surgery, despite what you sometimes read in the headlines.”

Keusch continues, “I think the media is our watchdog and it’s good for people to keep an eye on what’s going on, especially in safety issues. Physicians are doing surgery in their own isolated facilities and in surgery centers outside of hospitals, so there tends to be more variation in what’s done, the length of surgery, who does the anesthesia, and what the safety precautions are, so it’s good to constantly monitor the quality of surgeries being performed. As long as the media treats it in a non-sensational way, I think it serves the public good.”

Also serving patients’welfare is a mandate by ASAPS. In a definitive move toward patient safety in July 2002, it began requiring its members to perform all surgery (except those cases requiring only minor local anesthesia and/or minimum oral or intramuscular tranquilization) in facilities that meet at least one of the following criteria: accredited by a national or state recognized accrediting agency/organization; certified to participate in the Medicare program under Title XVIII; or state licensed.

“The documentation of such a high level of safety over a long period of time in an accredited outpatient facility confirms that the standards mandated by the recognized accrediting agencies, as well as good judgment by experienced and qualified plastic surgeons, do result in safe outcomes for patients,” says Malcolm Paul, MD, past-president of the ASAPS. “The fact that ASAPS members overwhelmingly supported this requirement demonstrates their absolute commitment to the highest standards of care.

We want patients to know that when they select an ASAPS member for their cosmetic surgery, they are assured that the highest standards have been met.”

A recent survey showed that 55 percent of ASAPS members operate mainly in officebased surgical facilities, and published data confirm that plastic surgery performed by American Board of Plastic Surgery (ABPS) certified surgeons in accredited office-based facilities has a safety record comparable to hospital surgery. In 2002, all members were required annually to submit a signed statement attesting to compliance with the amendment requiring mandatory accreditation. Failure to comply with the accredited surgical facility requirement would lead to sanctions up to and including expulsion from ASAPS membership.

To meet the mandate, surgical facilities must either have accreditation by a national or state-recognized accrediting organization; or have Medicare certification; or be licensed in the state in which the facility is located.

“I think accreditation was way overdue,” says Keusch, who adds that her office was one of the only offices accredited in plastic surgery for office-based surgery 12 years ago. “I joined this office in 1990 and it was accredited back then. That was not the norm; that was the exception rather than the rule. I think it has been a very good move and it will help increase patient safety.”

A new study on the safety of outpatient plastic surgery, which was first presented at a recent ASAPS meeting, documented 5,316 consecutive cases (primarily cosmetic surgery) and showed that accredited ambulatory surgery facilities provide patients with a reliably safe alternative to more expensive hospital-based plastic surgery.

Advances in technology and anesthesia monitoring mean that outpatient facilities can now duplicate the type and quality of equipment found in the traditional hospital operating room. As a result, there has been a dramatic increase in the number of outpatient surgery facilities in the United States. Current estimates suggest that 4 out of every 5 operative procedures will be performed in outpatient facilities by 2005, and that onequarter of these procedures will be performed in a doctor’s office.

The advantages of office-based cosmetic plastic surgery are many, ranging from cost savings to increased convenience and privacy for patients. However, concerns about patient welfare have been raised, with only a few published studies to document the actual safety record of outpatient plastic surgery.

The new study shows that in a sixyear period during which seven plastic surgeons performed 5,316 cases in a single facility, the rate of surgical complications (requiring a return to the operating room) was only 0.6 percent.

There were no patient deaths.

Study co-author Rod Rohrich, MD, says this safety record compares favorably with that of similar surgery performed in the hospital setting. One of the reasons for the low rate of complications was the care taken in patient screening and selection.

“The importance of a complete medical history in being able to anticipate and avoid potential problems cannot be overemphasized,” he says.

Another key to patient safety, Rohrich says, was a properly equipped facility. Outpatient facilities that meet national standards for accreditation must have equipment comparable to that found in hospital-based facilities, as well as backup support for vital equipment failures. They must be staffed with qualified anesthesia providers, nurses and board-certified surgeons who have hospital staff privileges to perform the same procedures being performed in the outpatient facility.

According to Keusch, patient safety is dictated by a number of factors. “From the very first office visit, the surgeons must identify that the prospective patient is an appropriate candidate for the surgery — not only physically, but mentally. Proper patient selection is absolutely key to the success of any procedure. Assuming that has been done, then making sure that individual is in his or her best health is vital. We do routine blood work, and if they are over 40 we get a cardiogram;

depending on their medical history we have them get a general check-up in a consultation with their internist. This helps us get a global view of their general health and what might need to be addressed before surgery. And assuming everything checks out, we proceed with the surgery in the right setting. An accredited facility is very important. I believe an MD anesthesiologist is the gold standard for outpatient surgery because if we are detached from the hospital, we are not able to contact someone in the same building and if an emergency occurs, I want to know that it’s another board-certified MD anesthesiologist who has the highest level of training to handle an emergency during a procedure. It’s also critical to have the proper monitoring after the procedure because when the patient emerges from anesthesia, there is a time when they are still susceptible (to complications) and not quite up to their baseline functions.”

A third factor in the low percentage of complications may have been surgeons’ decision to minimize performance of multiple, unrelated surgeries in the same operative session.

While some combinations of cosmetic procedures are safely and routinely performed with excellent outcomes, other combinations appear to increase surgical risks. Among the study’s more than 5,000 consecutive surgeries, approximately 10 percent involved multiple, unrelated procedures.

Keusch takes a pragmatic approach to unrelated surgeries. “I never say never because I think there are always exceptions to every rule. At a consultation outside of when an individual is already sedated, I think most of us would focus on the patients’ concerns and not volunteer other surgeries beyond what would be appropriate — unless there was a pressing reason to do so. For example, a rhinoplasty patient may have a very retrusive chin, so a chin implant may be appropriate but maybe it’s something the patient hadn’t considered but would strongly benefit from. Whereas if someone came in for a facelift, I wouldn’t say, ‘Oh but your nose looks like it really needs to be addressed.’ That would be inappropriate.

To bring up an unsolicited procedure while a patient is already sedated is not permissible because he or she can’t give an informed consent. It would have to be something that was life-threatening or mandatory in order to achieve the previously agreed-upon goals — but not an unrelated, totally ancillary procedure that had nothing to do with the original objectives.”

In another move to preserve patient safety, Keusch is particular about which surgeries are performed on an outpatient basis. Performing the majority of procedures in the office, she cautions that some surgeries should be reserved for the hospital setting.

“There are procedures I don’t consider for the office, including combination surgeries with prolonged lengths, such as a tummy tuck with a major suction or a breast procedure with a tummy tuck,” Keusch says. I do most liposuctions in the office but if they exceed four liters I always do them at the hospital.

The magnitude and type of the surgery dictate where they are performed. If I feel the patient may benefit from more than one overnight stay generally the hospital is the better setting for that. In Florida, we’re restricted to patient stays of 23 hours and 59 minutes. With procedures such as abdominoplasty, I tend to perform more of them in the hospital because there are times when the patient may want to stay a second day and that way we have a little more flexibility.”

Keusch’s discernment about environment of care is matched by her vigilance against performing surgery for all the wrong reasons.

A growing number of individuals suffer from body dysmorphic disorder (BDD), a syndrome in which patients coveting plastic surgery loathe their bodies and have an almost disabling preoccupation with imagined or slight defects in their appearance. A survey by the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) revealed that 6 out of every 100 women who seek plastic surgery suffer from BDD, as do 7 out of every 100 men.

“BDD is a very real entity and surgeons must be aware of which patients have normal desires for physical correction, those who want multiple surgeries, and those who are dysmorphic and have very distorted views of their body and just can’t stop wanting plastic surgery. Sometimes it can be difficult to tell the difference.”

Keusch continues, “The most common reason I would not treat someone who is looking to have plastic surgery is unrealistic expectations. Unrealistic expectations mean the patient won’t ever be happy with their surgical or medical outcome, whether it’s superb or it’s mediocre — and that becomes a lifelong issue for both of us. I think in those cases it’s better for us not to embark on a surgical journey that ultimately won’t make anyone happy.”

Just like matching the right surgery to the right medical setting, Keusch believes there should be a good match between the patient and the surgeon. Keusch says surgery centers should promote their physicians’ and surgeons’ qualifications and experience, in an effort to assure patients of their expertise.

“It’s important that patients do their homework and choose the right physician for the procedure,” she says. “They must find out if the physician performs a certain kind of surgery on a regular basis, and that they are board certified in their field. Most of us are happy to discuss with patients what our track record has been, what our comfort level is and what course of surgery or treatment we recommend for them. We should be very open about these things.”

ASAPS recommends that surgical centers encourage patients to do the following:

• Check surgeons’ credentials so that the physician’s training and certification are appropriate to the planned procedure.
• Certification by the American Board of Plastic Surgery (ABPS) ensures in-depth surgical training in all aspects of plastic surgery.
• Check the environment of care, and if undergoing a surgical procedure outside of a hospital, the facility should be accredited by a recognized agency.
• Check the surgeon’s hospital privileges. If a cosmetic surgical procedure is to be performed in an ASC or medical office, the surgeon should have privileges to perform the same procedure in an acute-care facility.
• Expect a thorough evaluation and informed consent, including the procedure’s risks and benefits.
• Plan on any necessary follow-up care.

Keusch says, “It is up to us as surgeons to educate the public. Education is key and making information available to the prospective patients is very important. But I also think the patient must assume some of the responsibility of researching surgeries and knowing what the procedure entails — especially what is medically sanctioned and what is not.”

Falling into the latter category are activities such as Botox parties, a trend surgeons like Keusch frown on.

“I always discourage medical treatment outside of a medical office,” she says. “Botox parties and social situations with injectibles are potentially very dangerous situations.”

Keusch feels similar disdain for another growing trend — bidding for plastic surgery via the Internet.

“I think there is potential for major problems,” she emphasizes.

“In our professional medical society we have a code of ethics that dictates that we not offer services in a contest situation or otherwise because we need to evaluate the patient and identify if they are appropriate candidates for any given surgery.

There is no way to do that in a contest or a bidding war. I think it takes away the professionalism of a medical surgical field to get involved in something like that.”

Despite the proliferation of aesthetic treatment on the fine line of legitimacy, Keusch thinks that plastic surgery attracts and retains qualified, dedicated medical practitioners.

“I really believe the vast majority of us who have reached this degree of training, education and specialization are here to provide excellent medical care to our patients, to ‘first do no harm,’ and to hopefully give them the surgical and medical outcomes they are looking for. I don’t think most plastic surgeons are motivated by purely monetary reasons; I think there would be easier occupations to pursue if that were the case.”

Top Surgical Procedures

The five most popular cosmetic surgical procedures in 2002 were lipoplasty (liposuction), 372,831; breast augmentation, 249,641; eyelid surgery, 229,092; rhinoplasty (nose reshaping), 156,973; and breast reduction (females), 125,614.

Six new surgical procedures were added to the ASAPS survey for 2002.

These included umbilicoplasty (belly button enhancement) and breast nipple enlargement, both of which have been reported as “trends” by the media.

ASAPS statistics show that the actual number of these procedures was extremely small, with umbilicoplasty ranking 32nd (2,082 procedures) and breast nipple enlargement ranking 35th (540 procedures) among the 36 procedures surveyed. Since 1997, the number of cosmetic surgical procedures performed in the U.S. has increased 67 percent, according to ASAPS statistics.

The top five nonsurgical procedures were botulinum toxin injection (Botox), 1,658,667; microdermabrasion, 1,032,417; collagen injection, 783,120; laser hair removal, 736,458; and chemical peel, 495,415. Botox injection continued to rank first among all cosmetic procedures, increasing a modest 4 percent since 2001 but more than 2400 percent since 1997.

Microdermabrasion showed the highest one-year gain of any nonsurgical procedure, up 13 percent.

Males had 12 percent (807,692) of all cosmetic procedures, while females had 88 percent (6,081,857) of the total. The percentage of procedures attributable to males and females respectively was virtually unchanged from 2001. The top surgical procedure for both men and women was lipoplasty.