Considering Cosmetic Surgery? Where You Have It Matters

From the WebMD Archives

Sept. 29, 2000 -- If you live in Florida and have been considering scheduling that facelift or tummy tuck, you may have to wait. In a measure that many are calling extreme, the state has banned in-office surgery requiring general anesthesia -- or being put to sleep -- for 90 days. Until Nov. 10, facelifts, tummy tucks, nose jobs, and liposuctions, among others done in-office, are out.

Right now, 15 states are contemplating regulating in-office surgeries that are dominated by the plastic and cosmetic industry. California, New Jersey, Rhode Island, Texas, Pennsylvania, New York, and Florida have all adopted guidelines regulating to one degree or another surgeries that require people to be put to sleep. In 1997, Ohio banned this type of office surgery altogether.

Many states, like Florida, grant an unlimited license to practice medicine, meaning anyone with an MD or DO behind his name can set up a practice to do most anything, David Mackey, MD, past president of the Florida Society of Anesthesiologists, tells WebMD. Therefore, a dental surgeon could do liposuctions, surgeons could give anesthesia, and anesthesiologists could do surgery. Mackey contends that when patients go in for an in-office procedure for plastic or cosmetic surgery, they do not know if the person doing their surgery has the specialized training necessary for that procedure.

In August, the Florida Board of Medicine placed the moratorium because of what it calls "an alarming number of deaths in Florida primarily related to plastic or cosmetic surgery performed in offices."

Georges El-Bahri, MD, chairman of the board of medicine, said in a press release that despite attempts to shore up protection for patients "20 adverse injuries related to office procedures have been reported to the board since March, including five deaths." Of this total, nine of the injuries and all the deaths were related to plastic or cosmetic procedures. The state is holding hearings during this period to consider how to institute regulations to better insure patient safety. The procedures can still be done in a hospital or outpatient surgery center during the moratorium.


Perhaps no medical discipline, especially in recent years, has undergone the economic boon that plastic surgery has.

Consider this: According to an American Society of Plastic Surgeons report published in 1999, the number of people who had cosmetic surgery procedures tripled since 1992. Liposuction alone leads the pack with a nearly fivefold increase.

This growth is due to many factors, especially a baby boom generation realizing while growing old is inevitable, looking old isn't. Physicians, some experts suggest, have latched onto this huge clamor for reclaimed youth by offering cosmetic procedures that bolster the lagging economics of their practices brought about by the long arm of managed care. And some of them may not be qualified to do the procedures, and their offices may not meet the standard criteria for doing these operations.

However, the boomers coming in for procedures from laser resurfacing to complete rejuvenation packages arrive bearing hard cold cash in their soon-to-be-ageless hands.

Many critics claim this industry has far too many mishaps and deaths for procedures usually undertaken by healthy people in their prime. Part of the problem may lie with a lack of regulation, but it also may rest with those who flock to the medical fountain of youth, not realizing that they are volunteering for major surgery.

Considering plastic surgery? You need to know the questions to ask before you slip under the veil of anesthesia to dream of your new 20-year-old-like face and body.

"I think the general public needs to know that it is their responsibility in determining if a physician is qualified or not," says Jeffrey Knezovich, executive vice president of the American Academy of Cosmetic Surgeons who opposes Florida's moratorium and mandatory regulations.

"We've all seen the documentaries where the patient thought she was being operated on by a plastic surgeon and it turned out to be [someone with] some other background. I think patients need to pick their surgeons carefully," says Walter Erhardt, MD, president-elect of the American Society for Plastic Surgeons. "There are a number of other self-designated boards."


Adds Lawrence Korpeck, MD, a Boca Raton, Florida-based plastic and reconstructive surgeon: "Many doctors say 'board certified' and are board certified in another specialty."

But is this wrong? Knezovich doesn't think so since oftentimes, doctors specialized in other areas do perform cosmetic procedures quite regularly as they've taken the necessary courses to do specific procedures.

Mackey, Korpeck, and Erhardt, while not agreeing on Florida's moratorium, do agree that patients should make sure that the surgeon performing their cosmetic procedures is certified to do that exact same procedure in a hospital or outpatient surgery center, not just in his office.

Korpeck adds that state regulations or not, the surgeons should have their office certified and inspected yearly by a respected agency, such as the American Association for Accreditation of Ambulatory Surgery Facilities.

Other questions to ask are how long the surgeon has performed the procedure, what emergency measures are in place if anything goes wrong, and who will be administering the anesthesia -- are they licensed and skilled to do so? Mackey, who would like to see an anesthesiologist overseeing all in-office procedures, does not think a certified nurse anesthetist only supervised by the surgeon is sufficient.

John Nawalanic, president of the Florida Association of Nurse Anesthetists, tells WebMD that nurse anesthetists have been delivering anesthesia in 90% of the office-based settings. While many of the deaths were anesthesia-related, he doesn't find this atypical of what would be found in a hospital setting. Not that any death is reasonable, he says, but as with any major surgery, complications can occur anywhere.

The bottom line is that this is major surgery, and patients need to be as informed as possible whether regulations are in place or not. The biggest problem is that this sort of "vanity surgery" may be taken too lightly by patients and some of the physicians performing it.

Korpeck is opposed to the moratorium, but in agreement with mandatory regulation of office-based surgery. "What the state has done is to put together an ad hoc multispecialty committee of surgeons, internists, and consumers to look at the problems and come up with guidelines for safe office-based medicine, which then they'll probably institute [them] at the end of the moratorium," he says.


It's the patients who are being hurt during this 90-day moratorium, says Korpeck, as they are losing the individualized care and privacy an office-based setting affords. He also contends that in an office setting, patients spend less time under anesthesia because the doctor does not have to train a hospital staff to his or her routine for each procedure.

On top of it, for this out-of-pocket surgery, in-office procedures are typically 30 to 40% cheaper than in a hospital or outpatient surgery center.

However, all experts agree that patients need to feel safe and overall to be safe. If you feel you'd rather have your facelift in a hospital where if anything goes wrong there is immediate personnel to step in, then that might be the best place to be.

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