Plastic surgery is all the rage — but it's rife with risk. What you should know if you're considering going under the knife.
1. "I'm actually a dentist."
Plastic surgery is a booming field. According to the American Society of Plastic Surgeons, more than 8.7 million cosmetic surgery procedures were performed in 2003 — an increase of 32% over 2002. Reality TV shows like Extreme Makeover and The Swan have helped popularize everything from Botox injections to tummy tucks.
Thanks to the increased demand, the number of doctors performing these procedures is surging too. But in most states, any MD can perform plastic surgery without board certification. That means anyone from your gynecologist to possibly even your dentist may be able to legally perform cosmetic surgery procedures.
The bottom line? "It's important to find out what kind of training your surgeon has," says Christopher Godek, a Toms River, N.J., plastic surgeon. Nearly all physicians are "board certified," but make sure your plastic surgeon is certified by the American Board of Plastic Surgery. ABPS qualification includes graduation from an accredited medical school and completion of five years of additional training as a resident surgeon, three in general surgery and two in plastic surgery. Doctors must then pass both a written test and an oral exam. To verify a surgeon's certification, visit the American Board of Medical Specialties Web site.
2. "That's not my specialty."
Just because a doctor is certified by the ABPS, that doesn't mean he's the right doctor for your procedure. A board-certified plastic surgeon who trained in reconstructive surgery and specializes in hand reconstruction, for example, probably isn't the best person to perform your face-lift.
Robert Kotler, a Beverly Hills cosmetic surgeon, recommends finding what he calls a "superspecialist" to perform your procedure. That means selecting a surgeon who has had additional training beyond board certification, in the form of fellowships. "Ask what their fellowship was in, and then what they specialize in," he says.
He also suggests calling a prospective surgeon's office and asking what procedures they perform most often. The surgery you're looking to have should rank at least in the top five, Kotler says — and preferably in the top three. "One of the dilemmas the medical world has is, there are so many procedures you can't master them all," he says.
You should also ask how many of those procedures the surgeon has performed throughout her career, says Jean Loftus, a Cincinnati-based plastic surgeon. Unless a particular procedure you require is especially rare, she says, "you don't want someone who only does a few of what you want done."
3. "This won't last forever."
Plastic surgery isn't as permanent as you think. "You're (still) better off 20 years down the line, but it's not a complete solution," says Z. Paul Lorenc, a New York plastic surgeon. "You continue to age. . . . And that's not discussed with patients to a great extent."
Certain procedures are more likely than others to need additional surgery. Breast implants from one of the two U.S. manufacturers, for example, have a 21 percent risk of needing another operation within two years of the initial surgery. "If you have breast implants, you must expect to have another surgery in your lifetime," says plastic surgeon Loftus. "Defiation, infection — just about anything can happen." Less invasive procedures can also have less-than-lasting results. Laser hair removal, for example, while often touted as a permanent solution to hair removal, "is not permanent," says Godek.
When consulting with your physician, ask how long your results will last. "A bump taken off a nose isn't going to come back," Godek says. "But for facelifts, even with the newer technology, most of us say they'll last about seven to 10 years." Maintenance is also important: Liposuction patients can't stop exercising or eat poorly and expect to stay slim; people who've had face-lifts need to stay out of the sun.
4. "It's the anesthesia you need to worry about."
With so much focus placed on the surgeon performing your procedure, the person performing the really dangerous part — administering anesthesia — is often overlooked. "I've been in practice for 16 years, and maybe five or six people have asked questions about the qualifications of the anesthesiologist," says Lorenc. But complications from anesthesia are far more likely to harm a patient than the surgery itself, as was the case with The First Wives Club author Olivia Goldsmith, who died last year from anesthesia complications at the Manhattan Eye, Ear and Throat Hospital.
Ask whether your surgeon uses a nurse-anesthetist or a board-certified anesthesiologist. "An anesthesiologist is a fully trained professional who is dedicated to that patient and doesn't have to be supervised," Lorenc says. But in many states, nurse-anesthetists do require supervision, and oftentimes your plastic surgeon will be the one doing the supervising.
That's not to say nurse-anesthetists aren't competent, but it does mean you should ask additional questions — like what the anesthetist's experience is with outpatient aesthetic surgery. If your physician uses nurse-anesthetists and you prefer a board-certified anesthesiologist, ask if it's possible to have one.
5. "My office may not be the best place for surgery."
Increasingly, plastic surgery procedures are taking place outside of hospitals. The American Society of Plastic Surgeons reports that 56% of all cosmetic procedures were done in an office in 2003 — a 6% increase over 2002. Another 16 percent were performed in ambulatory (nonhospital) surgical facilities.
The move away from hospitals isn't necessarily a bad thing, but it does mean you should ask additional questions. First, ask whether the facility is accredited by the Accreditation Association for Ambulatory Health Care or the American Association for Accreditation of Ambulatory Surgery Facilities. Both define hundreds of standards that address everything from safety procedures to patient selection. "Accreditation assures the public and the state that a given facility has met standards of care and is appropriately equipped and staffed," says Gerald Edds, president of the AAAHC and a facial plastic surgeon in Owensboro, Ky.
Accreditation is often the only way to ensure safety standards are being set — and met. Most facilities are not held to state licensing requirements, says Edds, and only a small percentage of offices performing plastic surgery are accredited. To find an accredited facility in your area, visit aaahc.org or aaaasf.org.
6. "My consultations are closer to sales pitches."
Choosing your surgeon is the most important decision you can make when having cosmetic surgery. It's imperative to pick someone you feel comfortable with. Consultations, then, shouldn't be high-pressure sales sessions but a friendly opportunity to ask questions and address your concerns. Make sure yours is with the doctor you're considering hiring and not a nurse or consultant. "It is a patient disservice if the doctor- patient relationship is supplanted by a patient representative," says ASPS past president Rod Rohrich. Surgeons who charge consultation fees usually apply the amount toward the surgery. "You're paying for a valuable service," says Kotler, who charges $175 for consultations. That service might mean being told surgery isn't right for you: Kotler estimates he turns away 20% of prospective patients. "I can afford to do that," he says, because he isn't giving away his time.
When Jennifer Grizzle, an Atlanta-based public relations consultant, had breast reduction surgery in 2000, she consulted three different plastic surgeons. The doctor she ultimately chose made her feel comfortable because he discussed her concerns at length in his office. "He talked to me with my clothes on in his office for 45 minutes before I was ever in an exam room with a drape on," she says.
7. "This will cost more than you think . . ."
Fees for plastic surgery procedures vary widely. A breast augmentation in Beverly Hills may be twice as expensive as one in Omaha. Even in the same zip code, fees differ. Les Bolton, a Beverly Hills plastic surgeon, recommends getting several referrals from doctors who have the credentials you're looking for and asking for their price ranges for a procedure.
But just because a quoted price is the lowest you find, it may not be the best deal. Several factors go into the price of a procedure, and not all surgeons include all elements in their quote. Besides the surgeon's fee, you'll also be charged for the surgical facility and anesthesia services, and possibly for other items like implants, medication and private home nursing care. Another hidden fee: revision surgery. While many surgeons don't charge for necessary touch-ups, you'll still pay for any anesthesia or facility.
After Carol Lewis, a Los Angeles public relations consultant, had a breast augmentation last July, she was put on five different medications-one of which wasn't fully covered by her insurance. Make sure you ask for quotes that include all the extras. The American Society of Plastic Surgeons also offers a list of the average costs of various procedures on its Web site.
8. ". . . but I do offer discounts."
Hiring a surgeon to perform a tummy tuck isn't like haggling for a car; for the most part, prices aren't negotiable. But that doesn't mean you can't get a discount. Physicians want their operating schedules full, and they often pay for surgical facilities whether they're operating on three patients per day or six.
Indeed, Kotler and Bolton say they have offered discounted rates of 10 to 15 percent off for patients who are willing to have their surgery on "standby" and be available on short notice if a surgical slot opens up. Another opportunity to save: the "Friends and Family" discount, when mother/daughter duos or friends schedule procedures for the same day.
Not all plastic surgeons are willing to offer such discounts, but most will reduce their fees when multiple procedures are done at the same time, such as a full facial rejuvenation comprising several separate surgeries. Since this also reduces the facility and anesthesia fees that would be spent on multiple visits, the overall savings can be as much as 35%. "Patients should ask, 'Can I work something out where I can save some money?'" Kotler says. "It's not demeaning or unprofessional."
9. "I'm not sure how safe this is."
Minimally invasive cosmetic procedures increased 43% from 2002 to 2003. The most popular, Botox injections, increased a whopping 157%. But not all wrinkle fixers available today have received Food and Drug Administration approval, and some that have are often used off-label. Restylane, for example, a popular material used to add fullness to lips and cheeks, didn't receive FDA approval until 2003, but was available for purchase in Europe and administered in the U.S. before that. Botox received FDA approval and was used off-label for cosmetic purposes before receiving approval specifically for brow furrows in 2002. Sculptra, another popular filler, has been approved for injections to fill the cheek hollows of HIV patients, but it hasn't been approved for general cosmetic use. "Be wary about using non-FDA-approved therapies for purely cosmetic reasons," says Loren Schecter, a Chicago plastic surgeon. "There's always something new coming out that gets a lot of hype, and people jump on the bandwagon."
Loftus recommends against being the first to try new procedures. "Let's wait and see what happens over five to 10 years," she cautions. "People (who got silicone injections years ago) ended up with nasty deformed lips and breasts." That was the result for one New York academic researcher. Two years after having liquid silicone injected into her lips, they started to droop. "I thought I was getting something completely safe and tested," she says. Instead, the material "made me look like I was frowning." She ended up having a plastic surgeon remove the silicone, at a cost of $1,250 per lip.
10. "Don't trust my before and after pictures."
Plastic surgeons love to show off the "before and after" pictures of their patients, but prospective patients should be skeptical. "The before and after pictures are typically of their best results — not their average results or their bad results," says Loftus. Her recommendation: Ask to see pictures of someone who was not happy with their results. "In my photo album, I have patients who are unhappy with their results, and I show them," she says. "I (also) show pictures of unsightly scars from breast lifts, because that happens, and pictures of breast augmentations without lifts." Daniel Man, a Boca Raton, Fla., plastic surgeon, agrees. "(Surgeons) should be honest and say, 'These are very good results,'" he says. "They should also show some that are not the best."
When studying pictures, look for similarities in lighting and background, as photographs can be altered and retouched. Another tip: Look for patients whom you resemble. When Jennifer Grizzle looked through her surgeon's photo book, she asked to speak to a few specific patients who, like her, needed breast reduction surgery but were otherwise petite. "That made a big difference for me," she says.