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Nip/Tuck Nightmare: The Dangerous New World of Cosmetic Surgery

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Whenever you consult a physician, you have the right to expect responsible, ethical care. Yet some MDs are playing fast and loose with patient safety, taking shortcuts and pushing procedures and treatments that may endanger lives. 

Who's holding the knife?
Debbie Daniels knew she wasn’t in the greatest shape. At 39, she still carried extra pounds from being pregnant. She worked full-time as a respiratory therapist in a Paducah, Ky., hospital, and no longer had time for the softball games that had once kept her active. But it never occurred to Daniels that cosmetic surgery might be the solution—at least, not until her OB/GYN offered to make some cosmetic tweaks at the same time as a scheduled hysterectomy. 

"He said, ‘We’re going to be opening you up anyway, and we can do a little tummy tuck while we’re there,’ " Daniels recalls. "It sounded so simple." The doctor had delivered Daniels’s last baby, and she knew him from the hospital where they both worked. "I thought he was a compassionate, caring doctor," she says.

But Daniels’s OB/GYN was not a board-certified plastic surgeon. According to lawsuits Daniels later filed, he’d even been placed on provisional status at another hospital for performing "modified abdominoplasties" without informed consent. During the surgery, rather than making a standard horizontal cut, he split Daniels open lengthwise, and removed not only too much skin but also important connective tissue. After several days, Daniels’s wound burst open, revealing a seven-inch-deep hole in her gut. She underwent emergency surgery and spent two weeks in a medically induced coma. 

Eight years and four major surgeries later, Daniels still has a mass of hernias in her belly, leaving her in constant pain and unable to bend over without risking a dangerous bowel obstruction. "I trusted my doctor when he said he could do this for me," says Daniels, who eventually settled a lawsuit against her doctor. "Now I know, too late, that he didn’t know what he was doing."

While Debbie Daniels’s case is especially frightening, her experience is far from unique. Under the right circumstances, plastic surgery should be relatively safe; the American Society of Plastic Surgeons (ASPS) reports that death occurs in only about one in 50,000 operative procedures.

But the growing popularity of cosmetic nips and tucks has made the field a breeding ground for exploitation.

Not surprisingly, cash is a huge factor. Last year plastic surgeons performed more than 1.6 million cosmetic surgeries worth almost $6.6 billion, a 9% increase over the year before. Other docs—OB/GYNs, emergency physicians—are also expanding into cosmetic surgery. A study published last year found that nearly 40 percent of liposuction practitioners in southern California were not trained as plastic surgeons. 

It’s not surprising: An OB/GYN might earn $2,000 for a C-section, while plastic surgeons on average charge more than $5,000 for a tummy tuck—typically paid for in cash, without the hassle of insurance company paperwork. 

"Physicians are pressed harder to make their livings, and are looking for ways to augment their income," says Dr. James Zins, chairman of the department of plastic surgery at Cleveland Clinic. "More and more, they’re turning to cosmetic surgery."

Of course, the way to make money as a plastic surgeon is to do surgery. For some, that’s an opportunity to layer on multiple procedures, try out an unproven new fad such as a "stem cell" face-lift, or take safety shortcuts that can endanger their patients. "I hear all the time of tragedies that occur," says Dr. Robin T.W. Yuan, a board-certified Beverly Hills plastic surgeon and author of Behind the Mask, Beneath the Glitter: The Deeper Truths about Safe, Smart Cosmetic Surgery. "There are doctors out there capitalizing on patients and doing procedures they shouldn’t. That’s how patients get hurt and die."

Plastic surgery used to be the exclusive domain of the rich and (sometimes) famous. Now, it’s attainable for almost anyone, thanks in part to the explosion in lower-cost cosmetic practices helmed by doctors from other specialties. But just because women can get cosmetic surgery from their internist or OB doesn’t mean they should. 

"Anyone can call themselves a cosmetic surgeon, with very little training," says Dr. Joseph Serletti, chief of plastic surgery at the University of Pennsylvania. "It doesn’t mean they have the qualifications to perform surgery safely." 

Dr. Felmont Eaves, a plastic surgeon in Charlotte, N.C., and immediate past president of the American Society for Aesthetic Plastic Surgery (ASAPS), says, "Doctors who are not board-certified surgeons are one of the biggest dangers in this field."

A board-certified plastic surgeon must undergo at least five years of specialized surgical training post–medical school. Doctors must then pass both oral and written exams and fulfill ongoing continuing-education requirements. "It should be the minimum of what you want from your surgeon," Zins says.

Yet none of that training is required by law. In most states, anyone with a medical license can perform cosmetic surgery. The results can be catastrophic.  Serletti says he and colleagues have seen patients come in with improperly placed breast implants and damaged facial muscles after going to poorly trained doctors. And yes, people do die: A recent German study of liposuction deaths concluded that lack of surgical experience was a major contributing factor. In July, Arizona internist Dr. Peter Normann, was convicted of second-degree murder and manslaughter after three patients died in his care, two after liposuction and the third after a botched fat-shaping procedure.

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A different path
Dr. Gregory Alouf is one physician who created his own route to cosmetic surgery. Alouf, a family practitioner in Salem, Va., opened an "aesthetics" practice in 2004, offering non-surgical procedures such as laser hair removal. In 2006 he began doing liposuction, followed by breast implants and other surgical procedures. According to a reprimand issued last February by the Virginia Board of Medicine, Dr. Alouf learned the techniques primarily at medical conferences, where there was minimal hands-on experience.

Two years after he started offering liposuction, Alouf performed lipo on an obese 29-year-old woman—someone the Virginia Board of Medicine stated "was not a suitable candidate for such surgery" due to her weight. Three other lipo patients experienced complications, resulting in hard and lumpy areas and "visible contour irregularities." (Dr. Alouf claims that those are the only complications he has had in more than 500 liposuction procedures.) 

In 2009, during a seven-hour mini-face-lift, Dr. Alouf’s 52-year-old patient started bleeding uncontrollably from her incisions. The doctor had her sit up and applied pressure to the site while he called a plastic surgeon friend for advice. As a result of these cases, the Virginia Board of Medicine ordered Alouf to stop all "full incisional" surgical procedures, stating that he "lacks the requisite education, training, experience, knowledge, skill, expertise and competence to perform such surgery."

Alouf says the issue is not competence, but competition.

"I have more liposuction training than a lot of cosmetic surgeons," Alouf says, adding that he’s never had a patient die, and none has ever filed a malpractice suit against him. "It all comes back to a turf battle," he says. "Plastic surgeons are defensive because there’s a lot of money involved, and they have very cleverly couched this as an issue of public safety to choke out the competition."

Money over medicine
It’s true that even board-certified surgeons can pose a risk to patients. Health’s investigation revealed these ways in which both unqualified doctors and board-certified plastic surgeons can be dangerous:
• Inappropriate procedures 
Sometimes, Zins says, refusing to perform surgery is the best medicine—if a patient is going through a divorce, for instance, or is dealing with depression. Other patients are simply physically unfit for surgery. Ideal liposuction candidates, for example, are relatively healthy, close to their ideal weight, with specific areas that need shaping.

But some doctors will operate on anyone with a checkbook. "A lot of doctors never say, ‘No,’ " Yuan says. "You should also avoid a doctor who tries to talk you into more procedures than you came in for." Generally the longer the surgery and the more areas being operated on, the greater the risk: One study found that combining a tummy tuck with liposuction increases the chance of death 14-fold compared to liposuction alone. 

"Unfortunately, to some doctors, doing more procedures is more important than patient safety," Eaves says. He adds, "We have a moral responsibility to our patients. The almighty dollar shouldn’t rule the roost."

• Following the latest fad 
Heard about laser liposuction, the technique that promises a faster recovery and more precise fat removal? So has every plastic surgeon in the country—both from manufacturer marketing materials and from patients, who have seen the ads and ask for laser lipo by name. Plastic surgeons say there’s no peer-reviewed data showing it’s any better than the traditional form of liposuction that has been practiced for years. In fact, they say, laser lipo may cause scarring that can’t always be corrected.

Laser lipo isn’t the first fad to hit the plastic surgery field, nor will it be the last. "We see new devices and procedures all the time that have marginal benefits, or may even be harmful," Dr. Eaves says, noting the buzz about "stem cell" face-lifts and breast augmentations; this technique, in which your own fat stem cells are injected into your face or breasts, gets a lot of hype but has little clinical data showing it’s either safe or effective. It can take years to prove that a plastic surgery innovation works—or doesn’t work—as advertised. In the meantime, "Many doctors feel they have to use these new techniques in order to get more business," Eaves says. "That’s a public safety problem."

A safer cut
You don’t have to shun the plastic surgeon’s office. But you do have to be extremely careful about who is operating on you. To guarantee at least a base of training, oversight, and experience, seek out a board- certified surgeon. Look for a doctor who is certified in plastic surgery; in some cases one certified in otolaryngology (for cosmetic surgery on the head and neck) or ophthalmology (for cosmetic procedures in and around the eyes) may be appropriate. (You can verify board certification at certificationmatters.org.) Check your state medical board’s website (find it at fsmb.org/directory_smb .html) to uncover whether the doctor has ever been reprimanded or had his license suspended for something related to his surgical practice.

Once you’ve established these basics, you’re ready to dig deeper. Don’t be tempted by a discount or payment plan—you should choose your doctor based on medical expertise, not price. The surgeon should lay out the risks and possible complications, and should be able to offer satisfied patients for referrals, not just show you before-and-after pictures. Considering a new procedure? Ask if there are clinical data on its safety and effectiveness.

Eaves points out that your surgeon should have a variety of techniques from which to choose to get your desired results—you don’t want someone who only does one procedure. He or she should outline the options and explain clearly why one might be better for you. Any good surgeon will also let you take your time making a decision, and even encourage you to get a second opinion.

 "You don’t want a doctor who talks to you for 10 minutes and then passes you to someone else in their office to seal the deal," says Yuan.

The bottom line is to make sure you understand exactly how the surgeon learned his craft, and what he is going to do to you. And if you’re not satisfied with what you learn, walk away. 

"I should have asked more questions, or simply said, ‘No, thank you,’ " Daniels says. "If I knew then what I know now about what he was doing, I never would have let that doctor cut me open."

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