With skyrocketing malpractice premiums and the Kafkaesque insurance system, it s little wonder M.D. s are flocking to the plastic surgery biz. It s easy to get into (legally, any doctor can do it), patients pay up front for surgery, and demand is up: The number of cosmetic procedures increased 59 percent from 2000 to 2007, making it a $12.4-billiona- year industry.
The best surgeons spend years honing their chops in residencies; by contrast, those hoping to offer a little Botox along with flu shots tend to opt for less rigorous training like the popular weekend classes at the International Society of Cosmetogynecology, an odd but official-sounding organization that promotes plastic surgery as an extension of gynecology. Its three-day courses cover liposuction and injectables. Empire Medical Training offers an even thriftier nine-hour seminar on lipo two hours of which are devoted to marketing.
Real plastic surgeons are appalled. Any licensed physician can put up a plaque and say they do plastic surgery regardless of training, and that s scary, says Roxanne Guy, president of the American Society of Plastic Surgeons (ASPS).
When 35-year-old Kelley Young of Fresno, Calif., looks at her wedding photos, all she can see is her plastic surgery disaster: Young s nose is bent to one side and its tip is misshapen. Those photos just look ugly, ugly all over, she says. Later, when Young went back to her doctor for a fix, he tried snapping her nose back into place without anesthetic. A year later she finally found a competent plastic surgeon to fix the problem.
Young is hardly alone. In fact, she s part of a new growth area in the field: fixing botched cosmetic procedures. According to a survey by the American Academy of Facial Plastic and Reconstructive Surgery, one in five nose jobs are corrections of a failed procedure. Stanley Frileck, an associate clinical professor of plastic surgery at UCLA, says that 35 percent of his work is fixing the mistakes of other surgeons. Botched rhinoplasty, face-lifts, and eyebrow procedures are the most common. Not only are these repairs more complex than the initial surgery but they can cost up to three times as much, Frileck says and the result is never quite as good as a welldone procedure would have been in the first place.
Just because you shelled out $10,000 for a face-lift doesn t mean you re set for life. Even the most skillful work will need some attention a decade or two down the line. Some jobs may require supplemental fillers (compounds that are injected under wrinkle lines in the skin) or minor surgery to tighten up a few sags, while others could call for a repeat of the same procedure. All cosmetic surgery has a life span, says Richard D Amico, president elect of the ASPS. Procedures will not last forever.
Surgery to tighten droopy eyelids, for example, often needs to be revisited after a decade, and any work on the lower face will age more quickly than that on the upper face, since the lower face is fleshier and has less bone for sagging jowls to hang onto. Breast implants are the most predictable: Like any foreign objects in the body, they ll eventually be surrounded by scar tissue, which can make breasts hard and painful. That s why every decade or two, depending on the patient, most implants need to be replaced. While 300,000 women receive implants annually, 25,000 have them removed. It s strictly a function of time, Frileck says.
Plastic surgery doesn t make you crazy, but those who have had it, both men and women, are more likely to suffer from psychological problems. Several studies in the mid-1990s found that women who chose to get breast implants were two to three times more likely to commit suicide; other studies have found that 20 percent of plastic surgery patients have undergone some form of psychological treatment.
Up to 15 percent of plastic surgery patients suffer from body dysmorphic disorder (BDD), marked by obsessive and exaggerated concern over aspects of one s appearance. It may sound like a convenient diagnosis for our beautyobsessed culture, but it is a very real, very dangerous condition, says David Sarwer, an associate professor of psychology at the University of Pennsylvania School of Medicine. At the extreme, people will not leave their home, they re so preoccupied with how they look, Sarwer says. BDD sufferers often seek plastic surgery hoping it will magically transform their lives, and when it doesn t, they may harm themselves. Every plastic surgeon worth his salt asks probing questions to gauge patients motives, but to date there s no standardized screening tool for BDD.
A board-certified plastic surgeon should be the best, right? Not always. Because any doctor can perform any cosmetic procedure, and because certification boards are self-regulating, many certifications aren t so telling. The American Board of Laser Surgery, for example, certifies nurses, veterinarians, and oral surgeons in laser surgery through a take-home written exam. Meanwhile, two different boards certify practitioners of mesotherapy, the use of injections to dissipate cellulite, although there s little evidence to suggest it works. To say you re board-certified is meaningless, says Michael McGuire, of the ASPS.
There are some certifications that matter: The American Board of Plastic Surgery is the most rigorous for this specialty and the only certification body for plastic surgery recognized by the American Board of Medical Specialties. Members of the ABPS have completed residencies in both general surgery and plastic surgery and are trained to do all procedures from liposuction to nose jobs. Likewise, physicians with board certifications in either otolaryngology or in facial plastic and reconstructive surgery also have reliable training in procedures above the collarbone.
When Janette McNeal decided to get some work done, the Tulsa, Okla., homemaker balked at the $10,000 cost of a faceand neck-lift. McNeal decided to look overseas, and wound up having surgery in Malaysia, where the same $10,000 bought her the face-lift plus liposuction in three areas, a tummy tuck, and an eyelid lift.
It s not for everyone, but medical tourism is less risky than it used to be. Since 2000, Joint Commission International, the international wing of an organization that accredits U.S. hospitals, has okayed 110 facilities overseas. Also, private companies that do their own screening have sprung up to guide patients through the process. One of those, MedRetreat, visits each hospital it uses and guarantees that the best surgeons will be on the case.
But medical tourism still has its hazards. It can be tough determining doctors qualifications, and eager patients may try to cram in too many surgeries at once, requiring a longer recovery and boosting the chance of lethal blood clots, a risk already increased by flying. Travel following surgery can also up the possibility of infection. And if something goes wrong, well, forget a malpractice suit.
The number of Americans who lose 100 pounds or more is increasing. But dropping the weight is just part of the process; next comes what s known as body contouring. After a person loses so much weight, his skin does not snap back, leaving folds of excess skin on his thighs, back, torso, abdomen, and neck, which can cause rashes and make fitting into clothes and exercising problematic. In many cases the extra skin must be removed through extreme versions of mastopexy (or breast lifts), tummy tucks, and other procedures. And there are often complications: The remaining damaged skin can die or separate after the procedure, requiring additional surgeries. Despite all the problems, body-contouring surgery is increasingly popular; between 2004 and 2007, the number of procedures increased by 20 percent, to nearly 67,000.
After Michele Fitch, a teacher in Melbourne, Fla., lost 190 pounds, she waited eight years to have the follow-up surgery. She wanted to make sure she could keep the weight off, and she needed to save money insurance often pays for the gastric bypass, but it rarely covers contouring. First she had skin removed from her arms and chest. Then 10 pounds of skin was cut from her sternum to her bikini line and from hip to hip. Out-ofpocket cost to date: $33,000. And Fitch still faces two more surgeries on her legs.
More than most other specialists, plastic surgeons are under pressure to compete with one another, and an easy way to get the upper hand is to offer all the latest technology. There is great pressure for physicians to jump on the bandwagon of a new filler or technique before it is really evaluated, McGuire says. And their ethics are not too high to begin with.
Doctors are often happy to try new techniques before the long-term effects are known, and in some cases they re performing procedures that already have poor track records. Injecting a person s own fat from other areas into her breasts for enlargement is on its way to popularity again. When this was tried years ago, much of the fat died, causing unsightly rippling and lumps. But that wasn t the worst of it: The tiny calcifications that resulted from the dead fat were easily confused with tumors and rendered mammograms less effective. While some argue that new techniques and better mammograms have eliminated these problems, McGuire is certain that this rush to the latest and greatest will once again produce disastrous consequences.
Fifteen years after the U.S. Food and Drug Administration banned them for elective use and after massive class-action lawsuits bankrupted their manufacturer, silicone breast implants have gotten the green light again. Though there s no conclusive evidence that silicone from ruptured implants causes the problems once associated with it, the FDA is staying cautious, recommending that patients undergo a long list of expensive follow-up tests over the long term. Due to concern about leaks, the FDA has required labeling that instructs those with the implants to get MRIs to check for ruptures after three years, then once every two years after that. Silicone implants should also be replaced every 10 years.
There s no actual mandate for these procedures, and some doctors say that patients won t follow through, especially once they start tallying the bill: The initial surgery can cost between $5,000 and $10,000; MRIs are about $1,500 apiece, and you ll need four over a decade; and the replacement surgery can cost about as much as the original procedure. Grand total: between $11,000 and $16,000 every 10 years.
Most people turn to plastic surgery when they feel age has finally caught up with them and nothing else will rid them of that troublesome bulge. But the dirty little secret of plastic surgery is that with many procedures, the more you need it, the less you can expect.
Those who have damaged skin, more common as we age, can expect some serious complications. Skin stretched by weight gain, for example, loses its elasticity; following liposuction it may not snap back into place but hang like an apron over the area that was suctioned. Because smokers have poor circulation to the epidermis, their skin can die after surgery, meaning months of unsightly scars and possible additional surgery. And procedures such as a face-lift done on sun-damaged skin won t last as long and may result in more-prominent scarring. Likewise, those hoping for dramatic weight loss from liposuction are looking in the wrong place; surgeons say it s meant only to shape a certain part of the body in conjunction with diet and exercise.
Ironically, those who need cosmetic surgery the least generally, those who are younger and opt for a little tweaking here and there are going to fare the best. How well a person cares for themselves throughout life is very important, says Mark Jewell, former president of the American Society for Aesthetic Plastic Surgery.