Beauty from Afar

Chapter 2 Page 7 | The Best of Both Worlds

John J. Corey, M.D., a prominent plastic surgeon in Scottsdale, Arizona, is an ASPS member. However, he also advertises a Brazilian influence on his practice and his technique; Dr. Corey traveled to Brazil in 1993 and studied under the aforementioned Ivo Pitanguy, M.D.

“Brazilian surgeons seem to have a different “eye” for aesthetic surgery … a different way of analyzing beauty and the human form. We Americans have a tendency to be very technical. We want to know exactly how much to contour and how much to measure. Brazilians seem to approach procedures more artistically. They don’t rely on applying the same measurement to every woman. They really believe in sculpting the form and creating the curves and lines of the feminine shape.”

Dr. Corey doesn’t deny the obvious implication of his own words — that many Brazilian surgeons are incredibly good and that U.S. surgeons can and do learn a lot from them. And, like many other surgeons in the United States and abroad, he has used the Internet in building and extending his own practice. He has patients from out of state and out of the country. He also knows that not all patients can afford his prices, and that excellent surgeons, board-certified in Brazil and other countries, charge far less than he does in Scottsdale.

“The ASPS is going to come down on the side of caution and safety,” Dr. Corey said. “And I don’t think anyone can fault them for doing that; it is what doctors do. But at the same time, of course, there are well-qualified surgeons around the world. We interact with each other; we learn from each other. And economic conditions, and the cost of doing business, are different in other countries.”

Dr. Corey looks at medical tourism from a pragmatic point of view. “I think we have to look at more ways to cooperate, more ways in which we can serve patients better,” he suggested. “Clearly, overseas surgeons who are able to charge less are meeting a need in the market, and the market is evolving. There are ways in which doctors in the United States can be part of that, and in which patients will benefit.”

The ASPS, he points out, does list on its Web site “corresponding members” from overseas; there are not that many surgeons who have chosen to affiliate, however, and the ASPS notes that it can not vouch for their credentials.

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Chapter 2 Page 6 | Point, Counterpoint

Rod Rohrich, M.D., a Dallas physician who is a past president of the ASPS, is (was) perhaps the ASPS point man for the briefing paper. He reiterated many of the points in the briefing paper, stood behind them, and referred me to articles in which he had been quoted.

“People want to go for the deal. They want to go abroad because, quote unquote, ‘They can get the same surgery for a reduced price.’  Therein is the fallacy,” is what Dr. Rohrich said in a Fort Worth Star-Telegram story in August 2004. “America has the best health care system in the world … You’re putting yourself and your body and your life at incredible risk.  Is it worth saving $500 on your face-lift if it could kill you? There are excellent surgeons in Mexico and all these countries. But I can tell you most of them don’t have these fly-in, fly-out deals.”

Ironically,  Luiz Toledo, M.D.,  a surgeon in Brazil who is active in the International Society of Aesthetic Plastic Surgery (ISAPS), referred me to the same news story when I asked him for the ISAPS perspective on the ASPS briefing paper. Dr. Toledo said patients generally look outside their own countries for better-quality services, cheaper prices, or a combination of the two. But he warned against seeking treatment from “cowboys” — untrained doctors with different specialties who perform cosmetic procedures for quick profits.

“A patient may travel to Brazil, Mexico, South Africa, or Costa Rica and have top-quality surgery with a cheaper price, due to the exchange rate or to economic differences between countries,” Dr. Toledo said. “It is wrong, however, and it should not be encouraged to travel for surgery only because it is cheap.”

It would be wrong to assume that Dr. Rohrich and Dr. Toledo have anything other than the highest respect for each other s abilities; they represent two points of view. Dr. Rohrich’s is that the risks of making a bad decision in choosing an overseas surgeon, and of traveling overseas for cosmetic surgery, are simply too high. “It has nothing to do with competition,” he said to me.

Dr. Toledo assesses the risks differently. In general, I have found that medical professionals do not want to make statements that mark them as at odds with their professional associations, associates, or peers. At the same time,  it would be a mistake to think that the briefing paper is representative of all opinions on the subject of medical tourism within the ASPS.

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(Author’s Note: The ASPS briefing paper referenced below has been revised and augmented with audio and video since 2005. Please visit this page at plasticsurgery.org for current information. However the overall advice remains true to the original briefing paper. If I were preparing a new edition of Beauty from Afar, this section would be rewritten … but would say many of the same things.)

Chapter 2 Page 5 | American Doctors Speak Out

What are the real risks against which to weigh the considerable cost savings? In April of 2005, the American Society of Plastic Surgeons (ASPS) issued a briefing paper that overwhelmingly cautioned against traveling abroad for surgery, though not in the stark terms used regarding going to the Dominican Republic. If one read nothing else, one would conclude that traveling overseas for plastic surgery is a poor idea. In the broadest context, however,the ASPS statement is full of sound advice for anyone considering cosmetic surgery. I offer the entire briefing paper, interspersed with commentary and context.

Cosmetic surgery tourism is a price-driven phenomenon that has experienced increased growth over the past decade. Numerous companies offering all-inclusive vacation packages that include cosmetic surgery are popping up all over the world and can be easily located via the Internet. The offers generally include private hospital services and tout “highly trained” and “credentialed” medical staff. Since elective cosmetic surgery procedures are not covered by insurance, price is the major selling point of cosmetic surgery tourism, with entire vacation/surgical packages costing less than individual procedures in the United States.

This is entirely true. Clearly, however, the ASPS disapproves of cosmetic surgery being a “price-driven phenomenon,” even as its member surgeons continue to work on devising lower-cost, less-invasive techniques and procedures and to compete with each other. U.S. cosmetic surgeons, however, in almost all circumstances, are unable to compete on price with their counterparts in the nip-and-tuck nations of Central and South America and Asia.

Although there are many skilled and qualified physicians practicing all over (the) world, the ASPS cautions that it may be difficult to assess the training and credentials of surgeons outside of the United States. Patients may take unnecessary risks, when choosing cosmetic surgery vacations, by unknowingly selecting unqualified physicians and having procedures performed in non-accredited surgical facilities. The ASPS urges patients to consider the potential complications, unsatisfactory results, and risks to general health that may occur.

Yes, it can be difficult to assess the training and credentials of surgeons outside the United States. Surgeons and facilities overseas that are marketing to prospective patients in the United States, however, have made it considerably easier. Overseas surgeons offer their credentials online, and ways of verifying them are available via Internet and telephone. Prospective patients can consult directly with surgeons and staff from other countries online; references can be provided and evaluated; consultations can be conducted by phone, e-mail, Internet chat, and even via Internet video. Indeed, many ASPS members are building Internet practices in exactly this way to draw patients from around the country and from abroad.

Plastic-surgery professional organizations, no doubt, would agree whole-heartedly that the ASPS certainly can not be faulted for urging patients to consider all possible risks and to be aware of selecting unqualified physicians who operate in substandard facilities. To that I would even add a further cautionary note: People who are considering the option of going overseas for cosmetic surgery, or any other kind of health care, should keep solidly in their minds that they must be ready and willing to walk away from the decision at any point: If they come to believe they have been misled about the surgeon’s expertise, the quality of the medical facility, the procedures involved, the price, or other terms, the right decision in the end may be to walk away. A patient who has done sufficient research is very unlikely to end up in such a position, but one must be mentally prepared to not go through with surgery if one develops serious doubts — even if it means cutting your losses on the expense of traveling there.

Vacation-related activities may compromise patients’ health. Cosmetic surgery trips are marketed as vacations. Although enticing, vacation activities should be avoided after surgery. To properly heal and to reduce the possibility of complications, patients should not sunbathe, drink alcohol, swim/snorkel, water ski/jet ski, parasail, take extensive tours (walking or bus), or exercise after surgery. Yes, some firms are marketing cosmetic surgery as vacation trips, and it is also true that some patients who go abroad allow for some vacation time by arriving early or extending their stays past the period of enforced recovery. Patients can certainly arrange to recover in comfortable, even luxurious, surroundings. But your surgeon abroad is going to tell you the same thing as well. Further, patients should budget extra time at the end of their trips, bearing in mind that complications and infections are possible and that you can not absolutely count on being physically ready to go home on a pre-arranged schedule.

Cosmetic surgery is real surgery. At the highest level of care, every surgery, including cosmetic surgery, has some risks. These risks may increase when procedures are performed during cosmetic surgery vacations. Infections are the most common complication seen in patients that go abroad for cosmetic surgery. Other complications include unsightly scars, hematomas, and unsatisfactory results. Travel combined with surgery significantly increases risk of complications. Individually, long flights or surgery can increase the potential risk of developing pulmonary embolism and blood clots.

Traveling combined with surgery further increases the risk of developing these potentially fatal complications, in addition to swelling and infection. Before flying, the ASPS suggests waiting five to seven days after body procedures such as liposuction and breast augmentation and seven to 10 days after cosmetic procedures of the face including facelifts, eyelid surgery, nose jobs, and laser treatments.

All good points, but it is also the same advice you would get from a qualified surgeon in any other country. Patients shouldn’t ignore this advice. I don’t mean to place blame, but far too many cosmetic surgery horror stories can be traced, in part, to patients not following a doctor’s orders for the recovery period.

Travel can be stressful and exhausting, and attempting it too soon after surgery can impede recovery. Despite the ominous tone of this caution, individual surgeons I talked to agree with this sentiment: Follow your doctor’s orders if you want your best chance at a trouble-free recovery. Don’t travel until your doctor says it is safe to do so.

In addition, airlines make special provisions for patients who are traveling with disabilities, and that includes travelers who have had recent surgery. If you have a long trip with flight changes, for example, it may be prudent to call the airline in advance and arrange for wheelchair service.

Follow-up care and monitoring may be limited. Follow-up care and monitoring is an important part of any surgery. Cosmetic surgery vacation packages provide limited follow-up care, if any, once the patient returns to the United States. Patients who have traveled outside of the United States for cosmetic surgery and experienced a complication may find it hard to locate a qualified plastic surgeon to treat the problem or to provide revision surgeries. Local doctors may not know what surgical techniques the physician used in the initial operation, making treatment difficult or nearly impossible. Revision surgeries can be more complicated than the initial operation and patients rarely get the desired results.

In general, this is true and should be considered carefully, especially regarding follow-up care. Some patients are afraid to tell their family doctors what they are going to do, or have already done. It’s best to be as prepared as possible for complications. Many experienced patients recommend consulting with your family doctor before going overseas. Also, reputable overseas surgeons are available for consultation with you or with your doctor at home via e-mail and telephone. This is not a deal-breaker, but it is something to think about.

Bargain surgery can be costly. Patients can incur additional costs for revision surgeries and complications that may total more than the cost of the initial operation if originally performed in the United States.

Well, yes. That can happen. Bluntly, it can happen in the United States as well, and you’ll be out far more money in the end. Choosing a qualified and experienced surgeon is your best chance at minimizing the risk of bad surgery that can lead to additional rounds of expensive surgery. Good cosmetic surgeons overseas often charge far less than good cosmetic surgeons in the United States. The ASPS cannot really quite get around that fact.

You should ask your surgeon in advance what his or her policies are on revisions, should you be dissatisfied. Some will do revisions for free, in certain circumstances, or for a reduced charge. A cosmetic surgeon’s best advertisement is satisfied customers.

Surgeon and facility qualifications may not be verifiable. In order for cosmetic surgery to be performed safely, it requires the proper administration of anesthesia, sterile technique, modern instrumentation and equipment, as well as properly trained surgeons. Vacation destinations may not have formal medical accreditation boards to certify physicians or medical facilities. Many facilities are privately owned and operated, making it difficult to check the credentials of surgeons, anesthesiologists, and other medical personnel. There are no U.S. laws that protect patients or mandate the training and qualifications of physicians who perform plastic surgery outside of the United States. There may be no legal recourse if surgical negligence by the physician or institution occurs.

If the surgeon’s credentials and the quality and standards of the surgical facility can’t be reasonably verified and vouched for, you shouldn’t go. Simple.

As to legal remedies, should a patient be dissatisfied with surgery — or maimed or killed by it — it is true that it is easier and far more convenient to sue a U.S. doctor in the United States than it is to attempt to litigate outside our borders. However, suing a plastic surgeon in the United States is far from a slam-dunk, and reputable surgeons here and abroad are generally willing to extend themselves to produce a happy patient rather than a disgruntled one who will call a lawyer.

Devices and products used may not meet U.S. standards. Cosmetic surgery products or devices used in other countries may not have been tested, proven safe and effective, or been approved by the U.S. Food and Drug Administration (FDA). For example, an implant used in the United States must meet standards of safety and effectiveness, a process regulated by the FDA. Other countries may not have similar regulations.

Patients should, of course, check on what substances are injected and what devices are being inserted into their bodies. However, one of the reasons many American women have gone abroad for breast augmentation is the availability of silicone implants, banned by the FDA in 1992 but popular in other parts of the world. It is possible that silicone implants may again be widely available in the United States because the ASPS says silicone is safe and that the FDA should drop the ban, arguing that patients should have the option of choosing silicone. The ASPS says silicone implants are safe and the FDA, at this writing, seems inclined to allow wider testing. The ban could well be lifted at almost anytime.

(Author’s Note: The ban was lifted in November 2006, five months after Beauty from Afar was published.)

The ASPS briefing paper goes on to name Argentina, Brazil, Costa Rica, the Dominican Republic, Malaysia, Mexico, the Philippines, Poland, South Africa, and Thailand as cosmetic-surgery trip destinations, noting that these countries offer everything from “safari and surgery” to “tropical, scenic tour” vacation packages. It concludes with a useful checklist of questions to ask when choosing a cosmetic surgeon, clearly advocating the selection of an ASPS member. Point by point, however, the briefing paper offers advice no different than one would get from a qualified surgeon overseas — and, the ASPS, however briefly, acknowledges there are many of them.

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(February, 2006)

At first blush, it may seem a bit odd that a board-certified plastic surgeon living and practicing in the United States is writing a foreword for a book detailing the ins and outs of getting cosmetic treatments outside of this country. What’s next? Major airlines offering insight into bus travel? At the risk of being called a heretic, however, there are several reasons why I think education about cosmetic medicine abroad is useful and why this book, Beauty from Afar, can be helpful for people considering surgery outside the United States.

First, let me say that I support the cautious position of the American Society of Plastic Surgeons (ASPS), detailed in this book, on travel abroad for cosmetic surgery. It is sound advice that I feel is inarguable. At the same time, the ASPS has been very good about including and cultivating the input and instruction of very talented surgeons from around the world. Their techniques are frequently included in ASPS journals and educational meetings.

On a personal note, I have been extremely fortunate to have spent time training with very gifted physicians practicing outside the United States, among them Dr. Ivo Pitanguy in Brazil. The techniques that I acquired while observing these doctors are an integral part of my practice today and are used on an almost daily basis. I have personally seen quality surgical skills outside of our borders.

When we talk about travel abroad for medical services, we are almost always involving an aspect of medical economics. We Americans know that we have an extremely competent medical system. But we also know that in relation to the rest of the world, we have the most expensive. Health care in America can come at a very high cost. This means that, at times, many Americans are unable to afford the highest level of health care services that they feel they may want or deserve. This is true of the aesthetic medical field as well. While my advice would always be to have your surgery done domestically if you can afford it, there are many people who simply would not be able to have a procedure done if they had to pay U.S. prices. In today’s global market where multiple companies and individuals are outsourcing to save on costs, it comes as no surprise that this phenomenon has surfaced in the medical industry.

Ultimately, however, quality and safety must be the top priority, whether you are seeking medical attention here or abroad. Unfortunately, in the United States as well as in other countries, there seems to be no shortage of unscrupulous practitioners who portray themselves as experts in their field, but who have never completed a recognized training or credentialing process. The medical experience for a patient is daunting enough, even in a qualified and legitimate familiar environment. Stepping over the border for equally qualified and legitimate care requires guidance. That’s why Beauty from Afar is so essential. This book provides individuals the necessary tools to make an informed decision when seeking out individual health-care options. Its solid principles apply to anyone searching out quality health care, whether across town, a border or the ocean …

John J. Corey, M.D.
Aesthetic Surgeon in private practice
Scottsdale, Arizona
U.S.A.
www.doctorcorey.com