Plastic Surgeons

The ASPS is the largest plastic surgery specialty organization in the world, with more than 5,000 member surgeons, and represents 94 percent of the board-certified plastic surgeons in the United States and Canada. Membership requires board certification by the American Board of Plastic Surgery or the Royal College of Physicians and Surgeons in Canada; regular participation in continuing education activities; maintenance of a strict code of ethics; and agreement by the surgeon to perform all surgeries requiring anything more than minor local anesthesia in an accredited, licensed, or Medicareapproved facility. Plastic surgeons may also belong to the ASAPS, which has similar membership requirements. Because these wellestablished organizations now require their members to operate in accredited facilities, a surgeon’s membership in one or both of them implies that he or she is committed to a higher standard of care.

Other Cosmetic Surgeons

Cosmetic surgeons from backgrounds other than plastic surgery may belong to one of the following professional organizations:

American Academy of Ophthalmology
American Society of Ophthalmic Plastic Surgery
American Academy of Otolaryngology—Head and Neck Surgery
American Academy of Dermatology
American Society for Dermatologic Surgery
American Academy of Facial Plastic and Reconstructive Surgery
American Society for Maxillofacial Surgeons
American Association of Oral and Maxillofacial Surgeons
American College of Surgeons

More information about cosmetic surgeon professional organizations can be found on their Web sites .

Hospital Privileges

Even if a surgeon has an offi ce-based operating room, anyone doing major cosmetic surgery will have some patients that need to be in a hospital. Find out where the surgeon has privileges to do surgery. Be concerned about a physician who does not have privileges in any hospital in your area, especially a surgeon who does not have surgical privileges. This may mean that the physician does not qualify for privileges, wants to avoid peer review, or has had problems and has chosen or been forced to leave a hospital staff. Any of these circumstances should make you think twice about picking that surgeon.

Some physicians do not carry liability insurance, which makes them ineligible for staff membership at most if not all hospitals. In any case, it bears repeating that a physician who has no admitting privileges at any hospital is not subject to the peer-review structure that helps identify and control bad doctors.

Experience

As in all of medicine, but particularly for surgery, your surgeon’s degree of experience is the best predictor of a good result. What if you don’t know which of several options is best for you or even if surgery is the best choice? Look for a surgeon who has a broad practice and is also experienced with both surgical and less invasive cosmetic procedures. It is perfectly acceptable to ask a surgeon directly how many of a partic ular operation he or she has performed. Also inquire about experience when evaluating providers of nonsurgical cosmetic medicine. Keep your antennae up when listening to the answers. Use common sense. If you were to develop a complication, you could fi nd yourself facing a serious medical problem that warrants no less attention than any other medical problem. You want to pick a provider who has the experience to manage complications appropriately.

References

Assuming that you have identified the cosmetic providers in your community who have satisfactory qualifications and experience doing the procedure you are considering, your best next step in choosing a physician is to seek out references from multiple sources.

Other Physicians

One of the best sources of information about a surgeon is another surgeon who has actually worked in the operating room with the provider you are considering. Because someone like that may not be available to you, ask your family physician or other physicians you know for a recommendation. Many cosmetic surgeons do other kinds of surgery as well, and your family doctor may have some insight into the surgeon’s abilities through mutual patients. Likewise, avail yourself of any opportunity to ask the physicians you know about the reputation of anyone you are considering to perform a nonsurgical procedure.

Previous or Current Patients

If you know or can arrange to meet someone who has been treated by the physician you are considering, you will get a lot of information about that physician. It helps to have more than one reference in case you happen to meet someone who seems excessively unhappy or even excessively happy with her result. The physician may be able to provide you with the names of patients who would be willing to talk to you about their experience, so ask about this at your consultation. Naturally, these will be happy patients selected by the doctor, but that does not mean that they cannot share a lot of helpful information and answer many of your questions. A few words of warning here since you will likely get a firsthand look at someone else’s result: everyone’s circumstances are unique, and your outcome cannot be fairly predicted based on that of another patient.

Friends and Family Members

Even though it is possible that no one you know personally has had a cosmetic procedure, you should still be able to find people who have experience with at least some of the cosmetic providers in your community.

Directories

You can find many lists of cosmetic surgeons and other providers, and they tend to fall into two categories: professional medical organization lists and commercial lists. The former can be obtained from the organizations (see Resources) and are generally more informative because they automatically tell you if a physician is a member of those organizations, that is, an ABMS- approved Board or a professional society that requires ABMS- approved board certifi cation. Commercial lists include listings in a telephone book, most referral services, “physician finders,” and many lists on the Internet. Physicians often buy these listings; there may not be any partic ular requirements as to credentials, and the lists give you no reliable information about quality of care.

Advertisements

In most markets, both good and bad cosmetic providers advertise. The occasional experienced, well-regarded surgeon may be so busy that advertising is unnecessary. By the same token, the physician who does little cosmetic work may decline to advertise for practical economic reasons. Therefore, you should never choose a provider based on the existence or lack of advertising alone. However, feel free to avoid a practitioner who puts out tasteless or obviously misleading ads. Likewise, beware of a clinic that sends out cosmetic surgery patients to display and market its services. For example, a Florida businessman, who compared his cosmetic surgery clinic to a used car lot, reported paying women who had undergone breast augmentation a 20 percent to 25 percent commission on new “sales,” often captured after a “show-and-tell” session.

THE CONSULTATION

Whose Agenda Is It Anyway?

Let’s face it: Doctors who perform cosmetic procedures want to sell them to you. That part of the consultation is not about your health: It is about the health of their businesses. The first meeting between a potential patient and a cosmetic medical provider is the setting for the sales pitch. Both parties are motivated to close the sale and, as a result, neither the patient nor the physician cares to dwell too much on the negatives. The fact that most cosmetic procedures are performed in an office or spa environment reinforces the idea that the procedures carry little risk. Dr. Goldwyn, in The Patient and the Plastic Surgeon, put it well: “If the office and the demeanor of the doctor and staff resemble more closely a beauty parlor than a medical facility, the patient will conclude that no ‘real operations’ with real risk are being done here.” One can substitute the more contemporary term “spa” for “beauty parlor” and easily see his point. Dr. Goldwyn goes on to point out that the surgeon “whose image is that of a highly skilled cosmetician may be surprised that patients do not consider him or her a ‘real doctor.’ ” That many patients continue to have this impression of cosmetic surgeons has been amply demonstrated in recent surveys, confirming suspicions that the public does not hold cosmetic surgeons to the same standards of knowledge or overall capability as it does other physicians. Glossy photo albums in the doctor’s waiting room showing nothing but amazing results (and by whom? you might ask) contribute to the red-carpet, fairy-tale ambiance. When you go to your consultation, arrive prepared with a written list of questions. This will allow you to listen to the doctor without worrying that you will forget to ask something. You may meet the physician only once before having surgery, and minimally invasive procedures are often performed during the first visit. If you are considering a more extensive procedure, you want to leave your consultation feeling confident that you have been given enough information and having a good sense of the doctor’s ability to meet your needs. Good physicians will go out of their way to try to provide patients with comprehensive information and will strive for the ultimate good result, a happy patient. These physicians will not try to convince patients to have more done than they need or to choose the one and only procedure (which the doctor personally invented) that will work for them. A patient should avoid a surgeon who makes her feel like an operation waiting to happen.

Consultation Fee

Some cosmetic providers give free consultations. Others charge a fee but may apply it to the cost of treatment or surgery. You should ask in advance; if there is a consultation fee, expect to pay it at the time of your first visit. Most offices take credit cards. History and Physical

The history and physical evaluation of a patient before a cosmetic procedure is usually quite focused on the partic ular concern for which the patient has made the appointment. But because psychological concerns can play a critical role in determining the patient’s eventual satisfaction with the outcome, obtaining a good history is an important challenge for providers. Physicians may not ask the right questions and patients may not volunteer helpful information. Patients should try to be honest and resist the temptation to give the “right” answer to questions in order to be perceived as a “good” patient. Practically every person seeking a cosmetic procedure has some degree of fantasy about the outcome, and these thoughts do not in themselves mean that person should be rejected as a candidate. On the other hand, patients cannot help bringing their personal value systems into the equation, and even though they assume that a physician would put a patient’s interests first, they should not assume that every physician shares their values.

Certain body parts—breasts, noses, and penises—are more symbolically loaded than others, and for some patients surgical alteration of these parts can be dramatically rewarding or psychologically damaging. A patient’s motivations, desires, fears, and expectations need to be identified and communicated to the doctor. Physicians know that you are more likely to be satisfied if you want a facelift so that you can look younger and compete in the job market than if you want a facelift so that you can feel more youthfully energetic or get a younger boyfriend.

Most cosmetic medical patients are healthy and their medical histories short, but be wary of a physician who does not request a thorough history. If your health history is extensive, write down the details at home, including the names of your other physicians, and bring the list with you. Especially important is any history of the following:

• Current medications: prescription medicines, vitamins, overthe- counter medications, occasional medications, inhalers, topicals, eye drops, nutritional supplements, and herbals • Use of steroids within the past year

• Current or recent (within six months) use of Accutane or topical retinoids

• Drug allergies, intolerances (including to pain medications), and reactions

• Latex allergy

• Allergies to foods, tape, dyes, iodine, or other substances

• Use of tobacco, alcohol, or recreational drugs

• Psychological problems, psychiatric treatment, or counseling for any reason

Your physical examination will include body areas pertinent to your symptoms and proposed surgery. Photographs may be taken. Some physicians use patient photographs for marketing purposes and are required to obtain your consent before doing so. Although you may be reluctant at first to have photographs taken, they can be extremely helpful to both you and your physician should you later have concerns about the results of your procedure.

Discussion

In conjunction with your exam the physician will ask about your goals and explain your options. If your goals are not realistic, now is the time to find out. At this point you should learn about risks, potential complications, and the anticipated long- term results of the procedure. You should be made aware of what specifi c characteristics you have that may affect your outcome, such as your current body part shape, your age, your medical conditions, and the condition of your skin. A thorough physician will point out existing asymmetries, as not all asymmetries can be entirely eliminated. If you are to have surgery, the surgeon will emphasize the extent of scarring that you can expect. You will learn what type of anesthesia your surgeon recommends, your options as to the facility at which the surgery will be performed, and your financial obligations. You and the surgeon (plus your spouse or parent, if present) should discuss these issues until you feel that your concerns are understood and that you are fully informed.

Do not be shy about getting the information that you need. When discussing cosmetic procedures, remember that you are hearing the “Botox talk” or “facelift talk” that the physician has given dozens of times, whereas you probably are listening nervously to it for the fi rst time. Physicians do not always pick up subtle clues that a patient does not understand some aspect of a proposed treatment. You should be concerned if the physician downplays or does not discuss any risks. If you have done some advance research, you will know if you are not getting the straight story. If you are not ready to make a decision, go home, think about it, and do more reading. Some physicians, especially surgeons, use computer imaging during consultations. Keep this fun technology in proper perspective. The computer is rearranging electrons, not human tissue. Computer images can be helpful educational tools but are at best an example or approximation of what your results might look like. Other doctors may show photographs of previous patients. Looking at pictures of other patients’ results is very dicey, in my opinion. Assuming that they are legitimate, they only demonstrate what was possible for that partic ular patient, which may have little to do with you.

Whereas some physicians rely on office staff, videos, or brochures to convey information to prospective patients, you should be sure that you are still given a face- to-face opportunity to ask questions of the doctor. You obviously cannot develop a comfort level with a physician if you do not spend time talking to him or her. Be wary if the doctor or the staff seem to be giving you a sales pitch for procedures other than what you came for. For the same reason, take note if your consultation is monitored or recorded. You may be told that this is for documentation or training purposes, but it may also mean that you are getting an extra sales pitch with your consultation. It should be a red flag if you feel rushed during the consultation. Some doctors view every minute the patient spends in the offi ce as an expense. You don’t want to feel like just another “case” on the schedule.

A consultation has been successful if at its conclusion you can answer at least the following questions:

• Is there a medical or surgical solution to my concern?

• What are the options?

• What are the risks associated with each option?

• Am I at any increased risk compared with a typical patient?

• How much benefit am I likely to achieve with the proposed treatment, and how likely is it that I will see no benefit?

• Where will the treatment/procedure be performed? Is the facility accredited?

• What kind of anesthesia will I have?

• How long does the treatment take and how much pain is involved?

• What complications could I have and how would they be treated?

• How long will the effects of treatment last?

• Will the treatment have to be repeated? How frequently?

• What will I look like after surgery?

• How much time will I need to be off work, and how much help will I need?

• How long will it be before I can resume all normal activities, play sports, wear makeup?

• Is this a good time for me to be undergoing this operation?

• How much does the procedure cost, including the expense of repeated treatments? Can I finance the expense?

• What is my financial risk if I have a complication? Should I purchase complications insurance?

The ASPS also recommends that you ask these additional questions of a surgeon:

• Are you an ASPS member surgeon?

• Are you certified by the American Board of Plastic Surgery?

• Do you have hospital privileges to perform this procedure? If so, at which hospitals?

• How many procedures of this type have you performed?

I recommend that you ask similar questions of anyone that you are considering to perform any procedure on you.

Decision Making

Decision making should come only after research and education, and if you did not research your options before your consultation, you should do it now.

Are you prepared to accept a complication? The greater the magnitude or risks of a procedure, the more time you owe yourself before making decisions about the physician and the procedure. Just as important, you need to have sufficient information about the circumstances under which the procedure will be performed (see page 149, Facility, Staff, and Anesthesia). Find out how available the physician will be after your procedure and how you can reach him or her if need be. Avoid the temptation to schedule surgery tomorrow just because the doctor had a cancellation.

An interesting and largely unresolved question regarding the relationship between a patient and a cosmetic provider is how much the physician’s opinion should enter into the patient’s decision as to whether to undergo a procedure. I am not referring to the physician’s technical opinion: Clearly, a physician should do only what can reasonably be expected to produce the desired physical change. (An unscrupulous practitioner, however, may not abide by even those constraints.) By opinion I am referring to the physician’s professional and personal judgment as to the wisdom of performing a partic ular procedure on a particular patient. Into this area of decision making comes a degree of psychological analysis (for which most physicians are not particularly well trained) and a measure of personal prejudice. Physicians must, if they are to do their jobs well, make some assessment of a patient’s motivations and psychological health. The teasing out of motivations requires a degree of time, patience, and skill that not all providers possess. On the other hand, a prospective patient might feel that questions designed to elicit motivations are intrusive and unnecessary. Experienced physicians know, however, that one of the biggest reasons for patient dissatisfaction after a cosmetic procedure is a discrepancy between expectations and results, even if the results are considered by the physician to be good. For this reason, a little extra time and care taken at this juncture can be invaluable.

Sometimes someone who is obsessive about cosmetic surgery shows up on a reality television show, and it is scary to watch a surgeon allow himself or herself to be talked into performing yet another operation, often with significant risks, on a patient who clearly could use a psychiatrist more than another procedure. These episodes remind me of time I spent in the late 1970s on the plastic surgery service at a well-known New York City hospital. One of the most memorable patients was a longtime customer of one of the attending physicians. This time she was requesting another in a series of forehead lifts and cheek enhancements for perceived irregularities in these areas. All I could see was a middle- aged woman who looked like a squirrel because her cheeks were strangely full, and her hairline, after so many forehead lifts, was on top of her head. I thought that she was more than a little unbalanced, but what was most disturbing was that the surgeon was agreeing to perform the new surgery she was requesting.

Financial Obligations

Even though price should not be the reason you choose a physician, it pays to do a little price shopping. Price matters because it can give you clues about your provider. Prices well below the average are a warning sign: You are likely to get only what you pay for and maybe more than you bargained for. Prices well above the average are suspicious also: This is someone who is willing to charge whatever the market will bear. Nobody is that much better than every other qualified provider, no matter what they say.

You may decide to pay for your treatment with cash or a credit card, and financing plans are available, most through outside companies. Because cosmetic medical care is always prepaid, you need to find out what happens to your money or how much you will owe the financing company if you cancel or reschedule, especially late in the game. You should also find out what penalties may accrue if you fail to meet the payment schedule.

It is important to clarify exactly what is included in a treatment package. For example, fees for surgery usually include follow-up care within a certain time frame. Find out how long that period is. Later “touch-up” procedures or treatment of complications may not be covered by the fee or by your regular health insurance. Look into this. Procedures such as laser treatments and injections may be sold in packages of multiple treatments that are discounted over the cost of the same number of individual treatments. Find out if there is a refund policy—it will probably be a partial refund for unused treatments. If you purchase a package that permits unlimited treatments within a time frame, think and calculate carefully before buying. Many types of treatment should be spaced out over a certain period of time in order to maximize benefit, so you may not get your money’s worth in an “all-you-can-eat” arrangement, especially if personal issues prevent you from keeping all of your appointments. The effects of some treatments last longer for some patients than for others. You may put yourself at a disadvantage if you purchase, let’s say, a year of hair removal laser treatments as opposed to a package of three or four that you can undergo whenever it is convenient. Total costs to you will include the procedure charge, possibly a separate facility charge, a fee for the services of an anesthesiologist if applicable, and in some cases a charge for the recovery facility. You may also be charged for drugs and wound- care supplies. In rare cases a patient may have a condition that is usually considered a cosmetic issue, but for whatever reason, treatment is partially or entirely eligible for insurance coverage. In this situation it is usually best to obtain advance confirmation of insurance coverage in writing through the standard preauthorization process. If you choose a surgeon who does not carry liability insurance and who is not on staff at any hospital, you may in effect remove yourself from eligibility for insurance coverage for that partic ular treatment.

Coverage of Complications Treatment

Most cosmetic medical patients will not develop a complication that requires hospitalization, but it does happen. Many health insurance plans do not pay for the treatment of complications that are the result of cosmetic interventions. In addition, most surgeons will not accept financial responsibility for hospital costs associated with the treatment of complications. In some cases medical responsibility for your care may be transferred to other physicians.

If you develop a complication, your physician may not waive fees for treating it, depending on the circumstances. These additional fees could be considerable, especially if you have to be hospitalized or undergo further surgery. You should discuss with the surgeon in advance how any complications will be handled fi nancially. Some surgeons provide patients with information from companies who offer complications insurance, or you can research that option on your own. Typically, this type of insurance covers treatment of medical complications related to a cosmetic procedure only if the patient requires more surgery or hospitalization. It generally will not cover the cost of extra doctor visits or more surgery performed to treat a patient’s dissatisfaction with an outcome.

Informed Consent

If you decide to proceed with a cosmetic medical treatment, you will be asked to sign an informed consent document. Before signing, make sure that you truly are informed; that is, the physician has explained and you understand the reasoning for the proposed treatment, the nature of the procedure, the risks, the benefi ts, and any alternatives. Informed consent is one of most difficult aspects of the contract between a physician and a patient; neither may feel entirely satisfied with the pro cess despite considerable effort. Physicians do not always do a good job of informing patients of the potential outcomes of the procedures and of the pain involved. On the other hand, it is widely known that patients retain very little of what they are told during a consultation; if asked later, they will often deny having heard certain information (despite documentation to the contrary) and many times will claim they learned about a subject from an entirely different source.

Doctor greets patient, who has come in for a laser hair removal consultation. Patient:“I liked your ad on television.” Doctor:“Maybe you heard our radio ad. We have never advertised on tele vi sion.” Patient:“No, it wasn’t on the radio. It was definitely on TV.” Doctor:“Oh, well, maybe you saw an ad for Dr. So and So.” Patient:“No, it was definitely you and it was defi nitely on television.” Informed consent is the cornerstone of good medical care, and nowhere is this more important than in the arena of purely elective cosmetic medicine. Obtaining informed consent is a professional, ethical, and legal obligation of physicians. However, patients must understand that by obtaining informed consent the physician has not guaranteed a partic ular result.

Some facilities, in line with accreditation rules, require that informed consent documents be signed within a certain time period before surgery, so you may not be asked to sign your consent form at the initial consultation. Nonetheless, be sure that you get the information that you need before you give consent.

FACILITY, STAFF, AND ANESTHESIA

If you decide to have a procedure, you want assurances that you will be cared for in a safe environment by well-trained professionals. One of the most important things you need to know is where the procedure will be performed and under what conditions, especially if you are to receive drugs. Your facility options may include a hospital, an outpatient surgery center, or an office surgery suite. Lesser procedures may be performed in an office, exam room, or medical spa treatment room.

Your provider may be employed by a facility or may have a fi nancial stake in it. If you go to a spa to get a facial, it probably doesn’t matter if the landlord is a cosmetician, a stockbroker, or a boardcertified plastic surgeon. However, prospective patients should keep in mind that venture capitalists may not have quality of care as their first priority. Some entrepreneurs operate retail facilities that are very cleverly designed to look “medical”—the front office may have official looking charts in a rack and the employees may wear hospital scrubs or lab coats—but no one present has any medical training. Do not let convenience prevent you from investigating your options as you move from cosmetics to procedures. If you are to undergo a medical or surgical procedure, whether it be an injection, laser treatment, or surgery, it needs to be performed or directly supervised by a qualified physician in an appropriate medical environment.

Any major surgical procedure, which includes any procedures with significant risks, should be performed in a facility that meets at least one of the three following criteria: accreditation by a national or state- recognized accrediting agency/or ga ni za tion such as the American Association for Accreditation of Ambulatory Surgery Facilities, the Accreditation Association for Ambulatory Health Care, or the Joint Commission on Accreditation of Healthcare Organizations; (2) certification to participate in the Medicare program under Title XVIII; (3) licensure by the state in which the facility operates. These requirements ensure that numerous safety measures are in place, including the availability of properly trained staff and adequate equipment to monitor you appropriately and to deal with complications or emergency situations. If your surgeon cannot provide you with this information about a facility, you can ask for a contact number so that you can make your own inquiries. You can also find out about a facility’s accreditation status by contacting accreditation organizations directly (see Resources). Not all states require accreditation of office and outpatient surgery suites, and some facilities do not want to pay the substantial costs associated with the accreditation process. However, many facilities fi nd it advantageous for insurance and public relations reasons to seek accreditation voluntarily. In addition to ascertaining facility accreditation, find out who will be administering your anesthesia or sedation. Anesthesia should be administered by skilled, licensed personnel acting under the direction of an anesthesiologist or the operating surgeon, and most professional organizations recommend that you avoid the situation where the surgeon is responsible for administering general anesthesia without a licensed certified registered nurse anesthetist or anesthesiologist present. You can check an anesthesiologist’s or a nurse anesthetist’s license status through your state medical board and his or her certification status through the Web site for the American Board of Anesthesiology or the American Association of Nurse Anesthetists.

Ask about the qualifications and number of medical personnel who will be in the operating suite during surgery. You should be assured that you will receive individual monitoring by skilled, licensed individuals who are trained in advanced cardiac life support. If the facility does not have overnight capabilities, there must be a transfer plan for patients who are not ready to go home by the end of the day. If the facility does have twenty-four-hour capabilities and there is a possibility that you will be kept overnight, you should expect to receive around-the-clock care and monitoring by two or more skilled and licensed staff members, at least one of whom is trained in advanced cardiac life support. Again, there must be a transfer plan in case you require hospitalization.

If you have a significant medical condition such as heart or breathing problems, you should have your surgery performed in a hospital so that appropriate resources are available to treat any problems that may arise.

The two major plastic surgery professional organizations most concerned with cosmetic surgery have adopted strict policies regarding the performance of office-based surgery. Both the ASPS and the ASAPS require their members to perform all but minor procedures that do not require more than local anesthesia only in accredited facilities. The ASPS and the American College of Surgeons have worked together to develop safety standards for offices. These standards can be viewed on their Web sites.

If you are considering undergoing any kind of medical procedure in a spa, be sure that a physician will be on-site, will participate in your evaluation, and will be able to perform or directly supervise the performance of the procedure. Only the simplest procedures should be delegated to a nonphysician and only then under good supervision. These are common-sense rules that will protect you even when inadequate state regulations do not. It won’t do you much good to choose the toniest spa in town if you develop a problem after a treatment and the doctor is nowhere to be found because he stops in only once a month. In the end, you must be satisfied with your answer to the question, Why should I submit to the care of a provider who is making a profit from unsafe and or illegal practices when there are so many well- trained and ethical providers and safe facilities from which to choose?

RECORD KEEPING

Physicians are expected to keep rec ords of patients and their treatments, but they do not have to keep those records forever. I recommend that everyone keep personal records of their medical care, especially of surgeries. You can ask your surgeon to provide you with a copy of the operative report from your surgery (you have a legal right to it) or you can keep your own notes.

Physicians watching these shows often comment on the eerie sensation of watching multiple episodes in which one technique seems to “fit” all candidates. Some patients have undergone procedures that to the educated eye look like shortcuts to fit the schedule rather than the best operation for the patient’s condition. In fact, participants on a cosmetic surgery reality show are only “allowed” to undergo procedures from which they can be completely recovered within the six- to- eight- week framework of the make over “incarceration.” Thus treatment is tailored to fit the show rather than the patient, hardly in keeping with putting the patient’s best interests fi rst. Others have procedures that produce dramatic Hollywood results but more than likely look “overdone” in the cold light of day, after the thrill of the experience has subsided.

A reasonable physician might question the televised medical decision making itself in some instances and wonder if it too has fallen victim to the pressure to create good stories. For instance, disturbing as it is to watch a cosmetic patient relinquish decision making to a doctor, it is just as upsetting to witness a surgeon acquiescing to unreasonable demands by a patient, apparently against his better judgment. In another example, we might ask if it is really necessary to perform an eyelid lift on a twenty-one-year-old. One patient lost 23 pounds in twenty days postoperatively; another had dropped 30 pounds three weeks after surgery. Should a physician be sanctioning rigorous weight loss and exercise regimens with a compressed time frame just weeks after so much major surgery?

More Is Better

By definition applicants do not get chosen for “extreme makeovers” if they only want to have one procedure, but they can still be on the show if they only need one thing done because “need” is irrelevant. The volume of procedures undergone by many patients on reality shows baffles and dismays many physician observers. The shows themselves downplay the number of procedures to which participants are subjected—many of the procedures actually performed are not identified until the operating room scenes or during the tally at the end of the story. Watching these shows one gets the impression that every feasible intervention is proposed to every participant. This feature alone redefi nes the role of a physician in the preoperative counseling phase in a way that many observers fi nd unacceptable. Leaving Out the “Care” in Medical Care Ethical concerns about the treatment of patients on television are not unique to critics of cosmetic surgery reality shows; the widespread use of private stories in the public forum of television raises numerous questions about ethics in broadcasting. Certainly, in the era of HIPAA (federal patient privacy legislation), it is ironic that so many people are willing to expose themselves (literally) to the world. Some scholars speculate that this is a neat turning inside out of the chilling concept of the near-universal presence of cameras foreseen by George Orwell in 1984.6 Instead of living in a society where surveillance is unavoidable, reality show participants mirror citizens with Web cams in their homes, voluntarily performing for whoever is watching. Still, the fl yon- the-wall format is a troubling phenomenon and begs the question whether individual participants, particularly patients, and their private stories are being inappropriately manipulated for public entertainment and commercial benefit through the pro cess of surveillance, analysis, and public display.

Invariably missing from all reality television programs is respect for the privacy and dignity of the participants, who are burdened with the physical and psychological stress of undergoing major surgery designed to result in a permanent change in appearance. The producers of cosmetic surgery reality shows make no effort to hide the fact that many participants ride an emotional roller coaster during their experience. If the patients’ apparently genuine displays of emotion are encouraged or somehow choreographed for the camera, then surely the producers and other members of the team have overstepped the ethical boundaries that should protect patients from unwarranted intrusions into their privacy. If the emotions are real and merely captured because of the constant presence of the cameras, then some of these patients are clearly in need of more emotional support than is being provided to them. In either case we appear to be viewing a much degraded method of the care and nurturing of patients whom medical professionals are morally and ethically bound to protect. The argument that these patients have been fully informed about the show’s expectations of them is specious because a patient in the pro cess of undergoing or recovering from general anesthesia and surgery is impaired and particularly vulnerable to anxieties and fears that do not apply to other reality show scenarios. It is inevitable that the presence of cameras, film crews, producers, and a host of other strangers irrelevant to the medical care in progress distorts and enhances the anxiety that naturally arises from the experience of undergoing major surgery. The contest aspect of shows like The Swan—the public embarrassment of participants as they are judged and found wanting—and the disgrace of producers requiring patients to undergo surgery and recovery in enforced isolation from families and friends, with only strangers with their own agendas to encourage them, are the antithesis of compassionate medicine. Follow-up stories on cosmetic surgery reality show participants have been few, but several have uncovered signifi cantly detrimental downsides to patients’ encounters with the reality show machine that remind us of the tales of destruction wrought on some recipients’ lives by winning a big lottery pot—coworker resentments, family strains, distressed children, and gradual dissipation of the glamour as real life takes hold once again. It appears that, like lottery winners, some makeover recipients are unprepared to cope with the potentially profound life changes that may accompany the physical ones.

Cosmetic surgeons have long known that undergoing a radical change in appearance over a short time is a major emotional stress, even if the physical results are pleasing. Reality shows do not acknowledge or take responsibility for guiding participants through this difficult period. “If you need us, by all means come to us,” a Time magazine article quoted Extreme Makeover producer Maria Brodsky. “But will we send doctors out to you and have them call you every week? No, because there is no need.”7 How she can know that just because the patients don’t call her, it is a mystery. When asked about contestants who seemed to be distraught, The Swan’s producer and contestant coach Nely Galen was quoted in People as saying, “Yeah, it was tough, but it’s also hard being on Survivor . . . That’s too bad. On our show, you don’t walk away with nothing, you walk away with $250,000 worth of services from day one. And that’s the price you pay.”8 In other words, you got a prize, so we don’t have to treat you like a real patient. The producers usually justify this poor treatment by stating that participants are told all the risks, implying that responsibility stopped with the telling. The emotional and psychological effects of radical makeovers are hardly limited to the recipients. Viewers might reasonably question, for example, the portrayal of a mother of very young children who leaves her family for two months, supposedly allowed only the occasional phone call, in order to undergo an assortment of cosmetic procedures, none of which under normal circumstances would have required her to be away from her kids for more than a few days or a week, all in the service of the dramatic imperative of a television show. It is incredible—medieval, really—that the producers would inflict such a demand on a family, yet these are the “rules” for those wishing to participate in this fantasy. Their family members, however, may experience the fairy tale differently. One patient’s husband declared, “The biggest difference was when she got her hair done” and another’s young child said wistfully, “I liked my old mom better.”

The Public Interest: The Impact of Entertainment Medicine on Viewers

One might argue that cosmetic surgery reality shows appear to be promoting a social hierarchy based on manipulated, celebrity-driven forms of appearance in which normal or average-looking people are not good enough and therefore should go to great lengths, expense, and risk to change. The suggestion is that if you are not movie star– gorgeous but not unhappy about it, there is something wrong with you. Likewise, if a celebrity is caught looking normal, he or she is deficient. A reader recently wrote to the Q & A column of a popular magazine with the following complaint: “With high- defi nition TV, I notice that aging actresses like Heather Locklear have fl awed skin. Can they do anything about it?” One can reasonably presume that an actress like Ms. Locklear makes a regular effort to maintain her complexion; however, she is, unfortunately, imperfect and requires the assistance of smoke-and-mirrors professionals to “fix” her fl aws. Underlying the absurdity of a celebrity appearance–based social hierarchy is the fraud exemplifi ed by I Want a Famous Face. Not only is it impossible to make someone look exactly like someone else, but the iconic image of a celebrity in many cases is the end result of cosmetic interventions, the attentions of personal trainers and chefs, the private indulgence in unhealthy practices like smoking and poor eating habits for the purpose of weight control, not to mention highly skilled makeup and hair artists and photo editing. The public knows this but doesn’t want to believe it.

The public should also be concerned about the other false messages about cosmetic medicine that emanate from entertainment sources: Cosmetic surgery is pain and risk free; multiple simultaneous procedures and long operations are no big deal; procedures entail little inconvenience or time off work; intensive, short-term therapy or “life coaching” can solve a variety of problems; marriages can be saved; job offers will flow in; physical fitness and stamina will improve; basic personality traits can be altered; the featured product Ethics and Cosmetic Medicine 95 and services are superior; providers are motivated to appear on shows and display their expertise primarily by a desire to perform a public service.

In the end, cameras or no cameras, the people who are selected to participate in these shows become patients, and they enter into a covenant with representatives of the medical profession in which the public imbues a trust. That solemn covenant cannot and must not be redefined as entertainment. Other observers have been blunter. Margaret Sommerville, founding director of the McGill Centre for Medicine, Ethics and Law (McGill University, Montreal, Canada), says there is “something obscene” about the phenomenon of cosmetic surgery reality shows. “[They show] a fundamental disrespect for the people in the shows and for humanity in general.”10 Do People Respect Their Doctors Anymore? Despite the decline in absolute physician authority during the past century, patients still tend to trust their physicians with a certain degree of blind faith, automatically granting them respect and assuming their professionalism. For the most part, media depictions of physicians, especially cosmetic medical providers, do not encourage this trust. The two image bogeys are the soulless entrepreneur and the godlike wizard. The first has already been addressed. As for the second, it is well known that cosmetic surgeons are often described, sometimes by themselves, in hyperbolic terms that defy gravity. The compelling idea of the “surgeon as artist” first sidesteps the fact that human bodies are not made of inert substances to be molded and re-created according to the surgeon’s personal aesthetic vision. The second trap that the “surgeon as artist” idea sets for us is the search for the holy grail, that universal and perfect form that does not exist, yet the application of individual surgeons’ concepts of it has led to untold numbers of obvious, unaesthetic, “done” results. To be sure, there are many surgeons in all specialties who are brilliant, creative thinkers and superb craftsmen and women, but beautiful results come only from excellent judgment, great skill, and even better luck.

If the greater public consciousness settles on the image of physicians as profit-minded businessmen before compassionate professionals, supersized egos before advocates, we physicians will have lost a public relations battle that will take more than one lifetime to undo.

ETHICS AND PROFESSIONAL ORGANIZATIONS

Some major medical organizations, such as the AMA, the ASPS, and the ASAPS, have written codes of ethics that address issues of physician behavior. The AMA is one of the few organizations to make its ethics code available to the public (see Resources). Those organizations also have mechanisms by which they can warn or censure member physicians who do not adhere to professional standards of conduct. However, just as physicians and other practitioners are not obligated to join professional organizations, they are not legally bound to observe ethical principles.

Enforcement of ethics rules by professional organizations is variable—in the case of cosmetic medical care it seems that, for the most part, organizations have neither the will nor the means to ensure that all of their members adhere to ethical principles. One can read the code of ethics of the AMA and contemplate whether its principles of respect for human dignity and rights; provision of relevant information to patients, colleagues, and the public; recognition of a responsibility to the community and to improved public health; and regard for the responsibility to the patient as paramount are upheld on cosmetic surgery reality shows. The ASPS code of ethics, a casual observer of the cosmetic medical landscape might be surprised to learn, is quite detailed on issues of misrepresentation and prohibits the organization’s members from exploiting patients’ anxieties and vulnerabilities. Lest one demurs that physicians are not ultimately responsible for the events on television shows, we must remember that these shows would not exist without surgeons to perform procedures and that at least one show advertises its stamp of approval from major plastic surgery organizations.

The AMA, in perhaps the best position to address issues that affect physicians from multiple specialties, has indicated some intent to address the ethical issues raised by reality shows. In a press release on December 4, 2004, the AMA House of Delegates stated, “Reality television shows that depict surgery should not minimize the seriousness and risks of surgery and distort patient expectations.” Clearly not certain that his organization has the clout to tell television producers what to do, yet wishing to remind physicians of their fiduciary duties to patients and the public, a trustee stated, “It is a physician’s ethical responsibility to accurately and openly discuss the risks and benefits of any treatment, including surgery. These reality shows need to follow the same ethical principles.” At that time the AMA announced a plan to formulate an opinion on physician participation in television entertainment programs. The panel assigned to develop the policy, the Council on Ethical and Judicial Affairs, has already issued a recommendation on protecting patients’ privacy in the presence of outside observers, and that recommendation has been formally adopted by the AMA: “Physicians should avoid situations in which an outside observer’s presence may negatively infl uence the medical interaction and compromise care.” As it has already been made abundantly clear that national television cameras in the courtroom affect the behavior of all of the participants in a trial, so must cameras in the exam room and the operating room inevitably influence the medical encounter.

THE PRICE OF PATIENT AUTONOMY

Ostensibly in the service of individual patient autonomy, our society has, by way of relaxed governmental regulations, allowed the health-care industry to target consumers directly in much the same way that other capitalist markets operate. As Tauber points out, some think that medical care should be considered a commodity; patients/consumers should be given more information and allowed to exercise free choice among health care options, which in turn should lead to better pricing and quality of care.Unfortunately, in the case of cosmetic medical care and many other areas of medicine, the ability of providers and manufacturers to market directly to consumers has led to the predominance of message over medicine, sales over science. Against the blaring background of commercialism and the steady erosion of patient care values, prospective cosmetic patients must rely on their own efforts to educate themselves about their medical care options, as will be discussed in the chapters that follow.

Certain cosmetic procedures may be described as minimally invasive; these are procedures such as injections, laser treatments, dermabrasion, and chemical peels that may cause less severe injury than a major operation. Minimally invasive does not necessarily mean minimally risky—patients have died from procedures that are sometimes dismissed as minor—and certain procedures, like liposuction, are considered invasive surgery even though they are performed through very small incisions. In fact, the size of skin incisions per se has little to do with the invasiveness or risks of a procedure. It is also inappropriate to consider procedures such as full-face ablative laser resurfacing and phenol chemical peels to be minimally invasive, as both create signifi cant burns. Noninvasive procedures are those in which there is no significant penetration of or damage to skin and underlying tissues. These procedures include certain laser and light-based treatments, microdermabrasion, and numerous newer procedures that may or may not have any measurable effects. Nonphysicians in nontraditional medical facilities such as spas and salons offer a variety of minimally invasive and noninvasive procedures.

Because many cosmetic medical services are not surgical and many providers are not surgeons, I frequently use the general terms “provider” and “practitioner” to refer to anyone offering cosmetic medical care services.

Cosmetic surgery is any invasive surgical procedure performed by anyone, regardless of training, for the purposes mentioned above. Most people do not understand the distinction between a cosmetic surgeon and a plastic surgeon. Cosmetic surgeon means the same thing in this writing as it does in the marketplace: it refers to any physician, regardless of qualifications, who performs cosmetic operations. Aesthetic surgery and aesthetic surgeon are terms used interchangeably with “cosmetic surgery” and “cosmetic surgeon.” In this book I use the term plastic surgeon only in reference to physicians fully trained in plastic surgery.Plastic surgery is used to denote the spectrum of operations typically performed by plastic surgeons, which includes operations on virtually all body parts rather than on a defined anatomic area (for example, the head and neck region or the eye region) or on an organ system (such as the digestive system or the skin). Many people have no idea what plastic surgeons do beyond cosmetic surgery. Plastic surgeons can replant an amputated finger and keep it alive, build a missing ear from scratch using other body parts, close a gaping leg hole that resulted from a motorcycle accident, repair an infant’s cleft lip and palate, and treat the wounds of a child burned in a house fi re. Most people do not know that the first successful kidney transplant was performed by a plastic surgeon who won a Nobel Prize for this accomplishment. Plastic surgeons also perform breast reconstructions and reductions, treat facial trauma and burns, perform hand surgery, correct congenital deformities, treat skin cancers, execute many forms of tissue transfer to heal wounds, and perform all types of cosmetic surgery.

Certain features of cosmetic medical care make the physician– patient encounter quite different from most other kinds of medical interactions:

• By definition cosmetic procedures are performed for the purpose of making a visible change to a body area.

• The patient initiates the encounter as the result of a psychological desire rather than a physical injury or disease process.

• The patient is positioned to maintain more autonomy in the decision-making process than is typical in a disease-driven treatment plan. Having said that, individual patients maintain or relinquish that autonomy to different degrees.

• Most patients are adult Caucasian women.

• All fees are prepaid or financed. Insurance coverage rarely applies.

• It is completely elective and, for most people, optional.

• Some potential patients feel guilt or embarrassment about seeking a cosmetic change; some insist on secrecy.

• The patient may undergo minimal pretreatment medical evaluation.

• The benefits of treatments may be exaggerated by providers.

• The risks of treatments are often downplayed by both providers and patients, as the consultation is a sales pitch and the patient is already interested in buying.

• Many procedures are performed in a physician’s office, a spa, or a salon; hospitalization is generally unnecessary or short term.

• A good outcome means that the patient is happy rather than “cured,” although happiness does not always correlate with a good physical result.

Cosmetic Vendors

Who is rendering cosmetic medical care in the twenty-fi rst century? There is a revolution going on. The availability and popularity of minimally invasive cosmetic procedures has turned nonphysicians into physicians, nonsurgeons into surgeons, and surgeons into cosmeticians. If you don’t believe it, just take a walk through your local yellow pages, read your local newspaper advertisements, or surf the Internet. It is no wonder that prospective patients do not know whom to trust.

There are an estimated 23,000 self-designated cosmetic surgeons in America today and an untold number of other practitioners offering less invasive cosmetic medical services. Several factors encouraged the expansion of cosmetic medicine in recent decades. Rules regarding physician advertising loosened; even mainstream cosmetic surgeons are now able to court their customers directly and do not have to rely on other physicians for referrals. Provision of cosmetic medical services has become an attractive way to boost income for many physicians. Last but not least, aging baby boomers are leading a wave of increased public demand for cosmetic medical services. Some, although no longer most, cosmetic medical care is rendered by board- certified plastic surgeons. Of the approximately 5,000 board- certified plastic surgeons in the United States and Canada, most perform both cosmetic and reconstructive procedures. The distinction between cosmetic and reconstructive plastic surgery is not rigid, and the techniques learned in one aspect of the specialty are often used to good advantage in other areas. From a practical standpoint insurance companies are mainly responsible for the push to classify procedures as strictly reconstructive or strictly cosmetic. Until recently, most cosmetic surgery was performed by plastic surgeons, partly as a natural outgrowth of our training to solve physical defects of form and coverage, regardless of location on the body, and partly out of an attempt by plastic surgeons to rescue cosmetic surgery from back rooms and beauty shops. The efforts by military doctors in World War I to find ways to treat war injuries gave birth to the formal specialty of plastic surgery, which has roots in older specialties such as otolaryngology, general surgery, ophthalmology, and dentistry. Plastic surgery remains the only specialty whose members are trained to perform cosmetic procedures on all body areas. Perhaps for this reason, the public today still equates plastic surgery with cosmetic surgery rather than with dramatic reconstructions. Many surgeons (and others) find a cosmetic practice appealing, for obvious reasons: The hours are predictable, most patients are healthy, the stress is low compared to other types of medical practice, and the pay is very good. Even though most doctors still fi nd rewards in taking care of sick and injured people, many surgeons from various specialties have increased their volume of cosmetic cases in recent years at least in part owing to the following specific circumstances:

• The volume of reconstructive cases in most plastic surgery practices has gradually but steadily lessened. Skin cancer reconstructions in ever-younger patients may be the only category that is expanding. Legislation mandating seat belts, air bags, lower speed limits, and stiffer drunk-driving penalties has reduced the rates of severe facial trauma. Burn centers and other specialized tertiary treatment facilities have taken patients with certain complex problems out of the care of community surgeons; lower birthrates have led to a drop in the prevalence of cleft lips and palates; technological developments have allowed many large wounds to be treated effectively without major reconstructive surgery; and numerous procedures that were developed by plastic surgeons have been incorporated into the training and practice of physicians in other specialties. As a result, larger than ever numbers of plastic surgeons report that cosmetic surgery composes more than half their workload. In geographic areas oversaturated with physicians or where insurance panels are closed to new doctors, cosmetic surgery may be what keeps some surgeons in business. Similar shifts are occurring in other specialties. As people stop smoking, the rates of head and neck cancers have gone down; antibiotics help patients avoid surgery by treating sinus and ear infections and tonsillitis; allergists and audiologists have taken over the care of many patients with allergy and hearing problems. These changes have all reduced patient and surgical case volume for otolaryngologists (also called ear, nose, and throat [ENT] or head and neck surgeons), some of whom have started to perform more cosmetic procedures. Dermatology has incorporated progressively greater amounts of cosmetic surgery into its training programs to the point of facing a manpower crisis for nonsurgical dermatologists. Likewise, ophthalmologists who had devoted substantial portions of their practices to the performance of LASIK operations face declining fees and stiffer competition for these patients, and some have increased their volume of cosmetic surgery procedures to compensate.

• Insurance reimbursement for reconstructive procedures has declined dramatically.

• Medical practice overhead expenses have skyrocketed in recent years, mainly because of repeated double-digit malpractice insurance premium rate hikes (the typical surgeon’s annual premium has doubled or tripled over the past decade and is now in excess of $50,000). By shifting to an offi ce-based cosmetic practice physicians in some states avoid paying malpractice insurance premiums altogether.

• The demand for cosmetic surgery and other procedures has increased such that even busy surgeons doing little cosmetic work regularly receive calls from patients requesting cosmetic procedures. Physicians from surgical specialties not known for their expertise in cosmetic procedures are among the many taking weekend courses, attending seminars, and meeting with sales reps with the goal of incorporating cosmetic procedures into their repertoire. The big boom in cosmetic medical products and minimally invasive procedures has encouraged nonsurgeon physicians to join the gold rush and add these goods and services to their practices. One cosmetic surgeon reported that he knew personally of a pathologist (one trained to do tissue and postmortem examinations) doing cosmetic procedures, despite never having examined a live patient in practice until he retired to a Sun Belt state. Not to be left behind, nonphysician wheelers and dealers set up clinics and spas, hire medical directors, and sell cosmetic services to whomever they can entice across their thresholds.

Although no one has a handle on the numbers, it is obvious that the number of cosmetic procedures performed in this country every year far exceeds the workload capacity of the qualifi ed boardcertified physicians currently in practice, even imagining that they are all working around the clock.