As long as doctors have difficulty earning a reasonable return in their core specialties, they will continue to move into other areas of practice.
Non-surgical doctors don’t really plan to one day pretend to practice cosmetic surgery – at least they didn’t used to. But faced with non-market determined administered fee schedules and market-based overhead, some have little choice but to attempt to escape their situation, and cash-based cosmetic procedures are one way to do that.
Rules on which type of doctor can do what type of procedure may be helpful, but can be abused.
Some plastic surgeons like to think they should have divine purview over the realm of cosmetic surgery. Being a plastic surgeon, I would benefit from such an arrangement. But it is not realistic and it is not ultimately in the best interest of consumers. Innovation and competition stem from intrusive forces, and as long as practitioners have the appropriate core skills to learn new areas of practice, stopping these does not make sense. Economic credentialing can be abused in the insurance-based as well as cosmetic areas.
Similarly, regulation of surgery facilities is reasonable for deep sedation, general anesthesia or large-volume liposuction. Facilities performing straightforward procedures under local anesthesia should be able to adhere to general good-practice standards without complex regulatory burdens. It is more important that the procedures performed are within the general scope of competence of those performing them.
Patients need to do homework to determine who should be treating them.
Some procedures are easier to learn than others; a cardiac surgeon and an ophthalmologist can both safely inject Botox. (Do not forget ophthalmologists pioneered it). But a patient who has a chest surgeon fix his detached retina and an eye doctor replace his aortic valve will likely end up blind and then dead. To some degree, regulatory boards and the need for hospital privileges can halt such practice drift far outside core areas of training, but they cannot and should not halt any practice migration. This is not in the best evolutionary interests of medical practice. There are appropriate and safe methods of expanding one’s practice area. Regulatory bodies should see to it that they are adhered to with patient safety as the primary concern.
Concerning the patient in the article, it seems fairly obvious that a nine-hour fat transfer is well beyond the typical duration for this surgery. Compartment syndrome is a known complication of fat transfer surgery, but the risk can be reduced by avoiding over-injection, especially in the lower buttock. Hopefully she will make a substantial recovery.
- Health: MedSpas Explode In Popularity, But Are They Safe? (philadelphia.cbslocal.com)
- Cosmetic surgery laws often aren’t enough (usatoday.com)
ABC ran a quality piece on certain cosmetic procedures to avoid, listing 10 problematic cosmetic procedures. Most of their discussion is right on target, but there are a few of these that may not be as bad as described. Here is the complete list with three underlined procedures and a discussion of each and why they may not be as bad as portrayed.
1 Fat dissolving injections
2 Cosmetic foot surgery
3 Permanent filler injections
4 Injection for breast augmentation
5 Cosmetic leg lengthening surgery
6 Buttock implants
7 Tatooed makeup
8 Extreme facial procedures
9 Combination mastopexy/breast implant
10 Any procedure by untrained hands
Injection for breast augmentation
The concern here is that augmenting the breasts with fat will somehow disguise the diagnosis of breast cancer. The reality is that nobody really knows this. It is very possible that calcifications from fat necrosis – possible after transferring fat to the breasts – will look different from the microcalcifications radiologists seek on mammograms. In selected people with proper anatomy (relatively non-droopy breasts, and enough fat for transfer), fat transfer could be a great alternative for a natural look and feel without the problems associated with implants. More research is needed. Due to the risk of lawsuits, most American surgeons will follow the lead from foreign surgeons once they get better at this procedure.
Cosmetic leg lengthening surgery
Admittedly, saying this procedure should not be avoided is a stretch (pun intended). Major complications, such as amputation and death, are possible. Though orthopedic surgery is not a cosmetic field, the principles of bone-distraction developed from trauma reconstruction can be applied for cosmetic use. Few surgeons do this procedure, but one is right here in South Florida. Dr. Dror Paley was highlighted on ABC’s 20/20 several months ago, and he does hundreds of these procedures per year, some for cosmetic indications. That being said, anyone considering this should do deep research due to the magnitude of the procedure.
Combination mastopexy/breast implant
The article correctly notes that these two operations somewhat counteract one another. But that is not a sufficient reason to rule it out entirely. Surgeons in competitive markets are at a disadvantage if they are not able or willing to do a mastopexy/augmentation. Many patients do not want to stage the procedure, and will go to other surgeons who can do it in a single stage.
Admittedly, if the breasts are very large or very droopy and the patient wants a large augmentation, staging is preferred and sometimes necessary. But for more moderate requests, this procedure can be done safely and effectively in the right patient and by the right surgeon.
- Unique cosmetic surgery moves body fat to breasts (vitals.msnbc.msn.com)
- Many women still opting for saline breast implants (mya.co.uk)
The authors retrospectively studied 65 cases of combined abdominoplasty and hysterectomy (the number of abdominal vs. vaginal hysterectomies is not mentioned, which is an important distinction).
The authors note a 32% overall complication rate, but state there were “no major complications…” they conclude that the combination procedure is safe and effective. But is this accurate?
It is not a randomized study, though performing such a study is impractical.
Commentary by Dr. Sherrell Aston correctly points out that a transfusion is not a minor complication.
A combination procedure that results in blood loss sufficient to warrant blood replacement is a significant operation. The specific indications for transfusion are not given, and it is possible more liberal criteria were used in the earlier years over the study’s range (1995-2011). Even so, it is rare to need a blood transfusion in cosmetic surgery. Most prudent surgeons would stage procedures that might result in the need for transfusion, such as substantial skin reduction surgeries following massive weight loss.
Below I present a sampling of various studies that have examined the combination of abdominoplasty with other intra-abdominal procedures over the last few decades. Rather than going through all the details here, I will summarize them below. Click here for each full reference.
The data shows that abdominoplasty combined with hysterectomy or other major procedure can be safe and effective. However, complication rates may be higher than with either procedure alone. It is difficult to be certain because most studies are retrospective.
Complication rates for combination procedures approach 30%. The risk of major complications such as transfusion or pulmonary embolism may have decreased in recent years, perhaps due to better preventive methods and tighter indications for transfusion. Obesity is one of the main risk factors for complications.
Patients interested in undergoing a combination procedure should carefully consider their options as well as the experience of their surgeon(s).
Combination procedures may offer advantages of lower cost and shorter overall recovery time. The chance of complications may vary between surgeons of differing experience, and patients who are obese or have significant medical problems can have a higher risk of perioperative problems.
- Is Combining Hysterectomy and a Tummy Tuck Safe? (news.health.com)
Europe’s debt and currency issues were briefly pushed aside when France recently announced that about 30,000 women should have removal of substandard silicone breast implants. Manufactured by Poly Implant Prothese SA (PIP), these devices may have a higher than normal rupture rate, and the company has been accused of using inferior, non medical-grade silicone.
Silicone breast implants have had a convoluted history in the United States, and were taken off the market for cosmetic use from 1992-2006. They were reintroduced with a new gel design and enhanced documentation and follow-up recommendations. Since silicone breast implants tend to touch off fireworks whenever they are in the news, here are a few points for Americans to keep in mind.
1) These silicone implants are not the ones used in the U.S. Ours are different, and the FDA warned the French company of manufacturing problems back in 2000.
2) The implants haven’t yet been proven to cause serious health effects. It will take time until experts can determine what, if any problems will be attributed to the inferior materials.
3) The potential safety issue is not the use of silicone in breast implants, but the use of non-medical grade material in the French devices.
Five years following the reintroduction of silicone breast implants in the U.S., an FDA review deemed them safe for use. The association with a very rare form of lymphoma was noted.
The French case says more on the issue of proper government oversight of product safety than it does about the safety of properly-designed silicone breast implants. The FDA deserves credit for their report regarding PIP’s manufacturing problems. However, there are many questions that have yet to be answered as to why French authorities took so long to discover and act on the problem.
The arrest of a Florida man for allegedly performing buttock injections with a variety of home-improvement products may seem shocking to outside observers. Not so in South Florida. We see a few a month. Some are not happy with the results; it’s lumpy, uneven, or otherwise abnormal. Those are just some of the patients. To see the others, we’d have to make rounds at the cemetery.
Amateur buttock enhancers are fairly prominent in the region, where there is higher than average demand for all sorts of cosmetic procedures. Buttock shaping is a popular procedure, and is fun and fairly straightforward to do. Properly selected patients tend to do well and satisfaction rates are high.
Perhaps due to the economy, or to ignorance, some people allow lay-practitioners (some may be partially medically trained) to inject substances into their buttocks, hoping to get the same effect as a proper cosmetic surgery. There are two things to keep in mind regarding this concept:
- There are only two medically legitimate ways (in this country) to reliably augment the buttocks: with silicone implants or with fat grafting.
Silicone implants are less commonly done since there are generally higher rates of complications than with fat grafting. They can be appropriate for thin patients who do not have enough donor area fat. But in general, fat grafting is the preferred procedure and makes up the majority of buttock enhancing procedures.
- Home-improvement substances such as caulk, silicone, Fix-a-Flat and cement (to name a few) are not supposed to be put in your body.
Though this should be obvious, not everyone realizes it. These substances are not designed for medical use, and can have all sorts of complications. There can be infection, hardening or destruction of tissue, and embolization (stuff entering blood vessels and clogging up the lungs or other organs). Any of these events can lead to irreparable tissue problems, disability, or death.
Some victims may believe that they are under the care of real medical professionals, (though I don’t know too many colleagues who perform procedures in basements or hotels). Others may not think these substances are harmful, or believe they are legitimate in other countries but not in the U.S. (they’re not).
Here is a brief list of similar incidents:
- ‘Buttock cement fixer’s bum deal’ (thesun.co.uk)
- Buttock enhancement is ‘the new boob job’ (mya.co.uk)
- Illicit silicone injections risky, even deadly: doctors (ctv.ca)
USA Today recently presented a multi-part series on cosmetic surgery. The first segment brought attention to the issue of physicians of many specialties diversifying into cosmetic surgery. I have discussed scope of practice before, and there are pros and cons with regulation of the cosmetic market. It is important for the general public to understand the due diligence that should be done before choosing a doctor.
But it is also important to acknowledge that there is a lot of self-interest and bias in the statements made on the subject by practitioners in all the relevant fields, including mine. If legislators ever took the step of placing cosmetic surgery solely within the purview of board-certified plastic surgeons, those surgeons would personally benefit. But the benefit to consumers would be highly questionable, and would likely not be enough to justify such an extreme step.
A key consideration that gets little attention is that many fields were pioneered by surgeons whose core training was in other areas. Thoracic and cardiovascular surgery, transplant, hand and plastic surgery, all were developed by surgeons stretching out into new areas. The obvious difference was that these fields were developed to solve difficult clinical problems, and not due to business considerations.
The next segment of the USA Today series described problems that have resulted from corporate entry into the cosmetic surgery field. Three firms were profiled, and in the interest of disclosure, I have provided independent-contractor services to one of them.
The general conclusion was that corporate efforts such as intense marketing and utilizing economies of scale is an unfavorable development, and associated with less satisfactory clinical outcomes. That conclusion is debatable. What is not debatable is that this type of market activity benefits consumers wishing to obtain equivalent services at much lower prices. It happens all the time in the retail economy, though the concept is new to this particular segment of the service economy.
Scope of practice and the role of “non-core” cosmetic providers is a contentious topic whenever it comes up among the various specialties involved. This is evident by perusing any “Doctor Message Board” website and following relevant posts. Often the commentary quickly denigrates in quality and becomes venomous.
A refreshing view of the topic is Jeffrey Frentzen’s editorial in Plastic Surgery Practice. He correctly points out the multispecialty contributions in the development of plastic surgery as a discipline. These influences were essential, but there are important differences between the World of Medicine in that earlier time and now.
Today, “non-core” practitioners do not enter the field to make new contributions, or to solve previously opaque medical problems. They do it mostly to improve their economic viability, which is very understandable. I think there are three points to keep in mind in order to have an intellectually honest discussion about scope of practice:
1) It’s about patient safety (partly)
The public deserves properly trained practitioners, yet there are many ways this training can be provided. There is no one foolproof method of training. As in insurance-based fields, many new procedures are learned after leaving residency. Training meant as an adjunct to an already competent practitioner is different from training designed to circumvent not having done a formal residency in a given area.
2) It’s about economic domain (turf)
There are some scope of practice battles in the coverage of hand and facial trauma, depending on the specifics of the community. There are far fewer battles over low remuneration reconstructive areas. If patient safety was the only concern, these would be contested as well.
3) It goes both ways
Each specialty has its area of core competence, and additional skills can be developed with training and experience. No specialty has maximal expertise over every area, and anyone can get outside of their “comfort zone” if they are not careful.
- Whistle blowing (nursingimpact.wordpress.com)