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Plastic Surgeons Respond to USA TODAY Investigation

Surgeons Explain the Distinction Between Hospitals and Outpatient Cosmetic Surgery Facilities

Last week, USA TODAY ran a front-page story and series of articles that explored risks of cosmetic surgery performed at “low cost, high volume” clinics.

A quote from the article titled “Cosmetic Surgery Gets Cheaper, Faster, Scarier

“While these centers typically employ board-certified plastic surgeons, some don’t have privileges to treat patients at hospitals, leaving patients to fend for themselves at emergency rooms. Soto says she now wishes she had her procedure performed at a hospital rather than an outpatient surgical center “so that if anything happened I was already there.”

But is a hospital the answer to all safety concerns? We asked several respected plastic surgeons to respond to this question.

David Robinson M.D., an Indiana plastic surgeon, writes:

I do not feel that all cosmetic surgeries need to be performed in a hospital. The outpatient facility though, should be an accredited one staffed by board certified anesthesiologists. It should also have a contract with a hospital in the event an unstable patient should require transfer. I personally operate at an accredited surgery center that is adjacent to a hospital. The surgery center is also staffed by board certified anesthesiologists. This gives both myself and my patients peace of mind.

Detroit plastic surgeon Dr. Ellen Janetzke offered a similar argument:

To say that the only answer is to do surgery in a hospital is too extreme and generalized. Some surgeries should be done in a hospital. Most surgeries should be done in an accredited facility. Minor procedures such as touch ups or mole removal that can be done under local anesthesia would be excluded from this. However, even with these surgeries, access to the physician (or staff) is necessary. The key word here is accredited. If the facility is not accredited and/or the surgeon does not have hospital privileges, buyer-beware. You do “get what you pay for.”

Seattle plastic surgeon Richard Rand says that outpatient surgery centers are necessary for controlling the cost of cosmetic surgery. He writes:

It is not necessary to legislate that all cosmetic surgery needs to be done in a hospital setting.  However, it is necessary that ALL cosmetic surgery be performed in nationally accredited outpatient surgical facilities by surgeons properly trained and Board Certified in Plastic Surgery who have hospital privileges to perform the same surgery in the hospital setting if that were necessary.

In fact, if it were mandated that surgery would all be performed in the hospital, I would estimate that the costs would skyrocket and that the quality would go down dramatically.  The costs would be out of the surgeon’s control and the hospitals would set fees very high to make up for their losses from insurance based care.  The quality of the care would suffer because the surgeon would be forced to work with staff from the hospital who were not necessarily familiar with the exact details of the techniques the surgeon uses.  In the best accredited office surgical centers, the surgeon has the top staff, they know exactly what will be done for each patient and they do this surgery regularly with the doctor, and the costs and scheduling are completely under the control of the doctor to best serve the patients.

According to Philadelphia plastic surgeon Dr. Bruce Genter, patients should have a choice about where their surgery will be performed. He explains:

Limiting all cosmetic surgery to the hospital setting is not the answer, except for procedures longer than 4 hours, which should generally not be performed in an outpatient center.  Instead, the doctor performing the surgery at an outpatient center must also have hospital privileges to perform that procedure and should be able to give the patient a choice to have the procedure in the hospital or the center.  All centers should have proper credentialing and a nearby hospital to where patients can be transported in case of an emergency.  Standards of care at a reputable center should equal the standards at a hospital.

On his blog, Houston plastic surgeon Dr. Young Cho describes some advantages of choosing a plastic surgeon with hospital privileges.

Advantages of having a procedure in the hospital setting is that there are more resources at the doctor’s disposal to address any complications that may arise from surgery.  Surgeons that work exclusively in the outpatient setting require very strong filters in choosing the right candidate for that setting.  Many patients perceive themselves as healthy, but there are certain screening factors such as body mass index (BMI), age, medical co-morbidities, that make some patients higher risk.

As with any business, there will be pressures to manage costs and look for new sources of revenue.  Practices that are exclusively clinic or outpatient based may be tempted to ‘loosen’ the criteria for patient selection to drive revenue and expand their market.  This is particularly true of ‘cosmetic surgeons’ with no formal surgical training beyond a weekend or weeklong course.  They cannot obtain surgical privileges at hospitals to perform surgeries so they are forced to do it in an office setting.  Likewise, they may not be able to obtain accreditation for an outpatient surgery center.  This limits their ability to safely deal with complications and often send complications to other surgeons, or the emergency room.

Dr. Chris Hess, a plastic surgeon near Washington D.C. responded:

I don’t think surgery in a hospital is necessarily the answer to safety concerns.  The answer is knowing your surgeon and that he/she is Board Certified, has a good reputation, discusses ALL of the pros and cons of the procedure, is willing to meet with you as much as necessary before surgery so that the patient is clear on what will happen, and determines if an out-patient facility or hospital is the most appropriate place for surgery based on the procedure, length of surgery, patient’s medical history etc.  Nothing should be rushed and no sales people should be involved.

Evaluating the Role of Computer Imaging in Plastic Surgery

A growing number of plastic surgeons are using preoperative computer imaging during patient consultations. These systems can be especially useful for procedures like rhinoplasty or breast augmentation, when patients are eager to visualize the expected outcome.

One popular computer imaging system (the Vectra 3D) captures 6 patient photos simultaneously. The computer then creates a three dimensional image that can be rotated and viewed from multiple angles. The surgeon can even overlay a ghost image of the expected outcome over the first patient photo to visually compare the differences.

But can patients expect these systems to predict their results with great accuracy? According to a study published in the current issue of Archives of Facial Plastic Surgery, their accuracy is moderately effective.

A study by plastic surgeon Umang Mehta was performed to “quantitatively measure accuracy of preoperative computer imaging as a reflection of postoperative rhinoplasty results.” To carry out the study, the doctor enrolled 38 subjects who underwent rhinoplasty. Both surgeons and non-surgeons were asked to compare the post-operative rhinoplasty photos with the predictive results from the computer imaging system.

According to the panel of expert judges in this study, the predictive accuracy of the computer imaging system scored a moderate rating of 2.98 on a 5-point scale. Slightly higher scores were submitted by the participating patients and non-surgeon judges.

What does this mean for the future of computer imaging in cosmetic surgery? The accuracy of imaging systems could (and probably will) be improved. But predicting surgical results is not the only aspect that matters in a surgery consultation. As the authors mention, viewing the 3D images is a “useful exercise,” just like your surgeon’s clinical before and after photos; they serve as a tool for productive discussion about aesthetics and shared goals for the procedure.

Surgeons Measure First Impressions After Restylane Injection

Can wrinkle correction change the image you project to the world? Surgeons at the Chicago Center for Facial Plastic Surgery sought to answer that question in a recent paper published in Dermatologic Surgery.

While many studies have documented the physical results achieved with dermal fillers like Restylane and Juvederm, few, if any, studies have documented how others perceive your appearance after such a treatment.

Using injections of hyaluronic acid filler, doctors fully corrected the nasolabial folds on 22 patients. To determine how treatment affected first impressions, they showed pictures of the patients to 304 people as blinded evaluators. They asked the evaluators about categories such as attractiveness, athletic ability, financial success, relationships and overall first impression.

“Significance was observed in all categories measured,” the authors conclude; “full correction of the NLFs with HA filler significantly and positively influences the first impression an individual projects.”

Funding and materials for the study were provided by Medicis, maker of Restylane.

You can access this study on PubMed