Beauty from Afar

In Beauty from Afar, I refer to Dr. Prof.  Ivo Pitanguy of Brazil as perhaps the father of both modern cosmetic surgery and of medical tourism.

Chapter 3 Page 2 | The Pioneers

I had originally hoped the Dr. Pitanguy would write the foreword for my book, but that wasn’t going to happen without my taking a trip to Brazil that I wasn’t able to take on my budget at the time. However, his office, in the person of Pitanguy’s then-assistant, Henrique N. Radwanski, M.D., was generous with time and information.

Chapter 3 Page 2 | The Pioneers

Brazil, in particular, gradually became known internationally for the expertise of its aesthetic and plastic surgeons, but it was not a fame that extended to the mass consumer markets of the more economically developed world. Prof. Dr. Ivo Pitanguy is not a household name outside of his home country, where he is revered. Dr. Pitanguy has performed or guided thousands of surgeries in a storied, five-decade career and has trained more than 500 plastic surgeons from more than 40 countries who practice internationally, making cosmetic surgery expertise and technique one of Brazil’s best-known exports.

Among his peers, Dr. Pitanguy is regarded as the father of modern cosmetic surgery. He also has become the father of modern medical tourism, for those he has trained are among the most sought after surgeons in the world. Yet his name and his work, outside Brazil and South America, are familiar primarily only to other plastic surgeons, Brazilians living abroad, and the families and friends of his patients — not to the millions of potential plastic surgery patients in the United States who are far more likely to know the names of surgeons on Dr. 90210 or The Swan.

In the United States, if one had to name a doctor who was famous in international medicine during the 1960s, perhaps the only household name was Christiaan Barnard, M.D., the South African who performed the world’s first heart transplant in 1967. Notably, Dr. Barnard trained in the United States, as did Dr. Pitanguy, before heading home to eventual renown.

I cite Dr. Pitanguy and Dr. Barnard as pioneers not so much for their unquestioned skill as surgeons but because they achieved the kind of international fame that, for most of the 20th century, was reserved for doctors and scientists only in the West (North America and Western Europe) and, to a lesser degree, the East (mostly the former Soviet Union). Patients in Eastern bloc countries frequently traveled to the then-USSR and its allied nations for advanced medical care. For all of the 20th century, and even into the beginning of the 21st century, the vast majority of medical tourists were not jetting to South America or Africa, let alone the Far or Middle East. They were coming to the world’s great doctors and hospitals in the United States and in Europe.

From the perspective of the United States, in particular, this state of affairs served, and still serves, to reinforce the generally held belief that the United States has the finest medical care in the world. In the last 50 years, only Dr. Barnard’s achievement challenged this notion in the popular imagination. People were oddly comforted when Drs.  and Michael DeBakey started transplanting hearts in Houston, Texas, almost in the same way they were when the United States finally answered the Soviet space challenge of Sputnik.

Meanwhile, Dr. Pitanguy just kept doing what he was doing. Patients spread the word. Brazil was and is the mecca of plastic and cosmetic surgery, challenged only recently by Southern California. The surgeons Dr. Pitanguy trained spread out through South and Central America and around the world. Over time, a second essential precondition for medical tourism to emerge as big business was met — medical talent spread out, belonging less exclusively to the developed world. In economically emerging nations, improving health care was a priority — which meant building more modern medical facilities.

The quality of care in the less-developed world rose steadily, at least in metropolitan areas, but prices for medical services remained low, relative to the United States and Europe.

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Chapter 2 Page 9 | Prices in the United States and Abroad

Consumers who consider going abroad to save money for cosmetic surgery, dental work, or any other kind of medical care, will hear these bromides, either from voices in their heads or from well-meaning friends and relatives:

• You get what you pay for.
• If it sounds too good to be true, it probably is.
• Quality doesn’t come cheap.

One does not have to have an intimate knowledge of international economics to understand why prices for high-quality cosmetic surgery can be far lower in less-developed countries than in the United States or Western Europe. A good surgeon is an artist, a psychologist, and modern-day wizard of sorts who transforms and restores; but he or she is also a businessperson. Cosmetic surgeons treat patients and are paid fees; cosmetic surgeons whose services are in demand can and do charge higher fees.

Simple, right? You get what you pay for, and quality doesn’t come cheap. However, among other things, geography matters a great deal. In your own town or city, you may find a range of prices from different cosmetic surgeons, as you might expect. Well-known surgeons with years of experience and hundreds or even thousands of satisfied customers will charge the most. A surgeon fresh from his or her residency, just starting out, trained but relatively inexperienced, will charge less. It is not unheard of for surgeons just starting out to offer reduced fees to clients who will agree to provide testimonials or referrals or otherwise participate in marketing the new business.

In your town, there will also be doctors and surgeons who may not be board certified in plastic surgery who nonetheless legally practice it, to an extent. The ASPS warns that such practitioners may be less-safe choices and, generally speaking, one would guess that they are right. Still, it goes on.

The average price of a typical facelift in the United States performed by a board-certified plastic surgeon in an accredited surgical facility, including surgeon’s fee, anesthesia fee, and operating facility fee, is in the $7,000 to $9,000 range, according to InfoPlasticSurgery.com (2005)

That might be the range in your town. But if you live in New York City, the range might be 50 percent higher. If you live in parts of the less-urban South or Midwest, the range might be a little lower. Geography matters, even within the United States. There is more demand for cosmetic and aesthetic surgery and procedures in urban areas and on the coasts; and the costs of living and of doing business are correspondingly higher. So how can board-certified, experienced surgeons working in modern facilities in Mexico, Brazil, Costa Rica, the Dominican Republic, Thailand, India, and other countries charge so much less? While a facelift abroad is more likely to cost between $3,500 and $6,000, including travel, meals, and accommodations, the costs of living and of doing business is correspondingly less in these countries. The top surgeons in the world, those with international reputations, can charge and get U.S. prices wherever they may be, but the many trained and qualified surgeons who aspire to be known as among the elite in the world must charge far less to draw patients from abroad, including the United States. And they can make a good living doing so.

Many think U.S. surgeons are greedy, but I do not think that is the case. They face significantly higher costs than do their counterparts and peers in other countries. In many ways, the reasons prices for cosmetic and other surgeries are lower in other countries than in the United States and western Europe are the same reasons why it is less expensive to produce DVD players or textiles abroad: They have less-expensive land, less-expensive construction costs, lower labor costs, lower taxes, and lower administrative costs. It is a mistake to single out any one thing as being responsible for the difference.

Malpractice insurance costs are also partly to blame. Though malpractice rates vary, depending on amounts of coverage, U.S. surgeons I interviewed said they each pay between $40,000 and $70,000 annually, compared to the less than $6,000 a year a Brazilian surgeon I know pays. This is a substantial difference, yet a small part of the overall equation. About the only business expense that is the same for surgeons regardless of where they live is medical equipment and medical supplies.

Price is relative from country to country, and a patient looking at the possibility of traveling abroad for care can responsibly factor that in. Some prices are so low that one can not help but be suspicious. Substantial inquiries are merited and references should be required. Cosmetic and elective surgery prices in the Far East are, for the most part, somewhat lower than those in South America, which are somewhat lower than those in Central America. I know that there are good surgeons in all those places.

Surgeons in the Far East, in fact, may be more likely to have trained in the United States and be fluent in English, though they have no monopoly on either of those things.

The cosmetic surgeon who charges the highest prices in your town may well be among the best and will almost certainly be among the most experienced. But paying the highest price does not guarantee the best outcome. Is a $10,000 face-lift in New York City better than a $7,000 one in Cincinnati? Is either better than a $3,000 one in Brazil? It depends.

I have talked to people who are unhappy with their expensive cosmetic work and people who are thrilled with the quality of their inexpensive results. For every anecdote, there is another one to give lie to the first. Beyond the borders of the United States, options abound for those willing to take the time to investigate, analyze, and choose.

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Dr. John Corey, an aesthetic plastic surgeon in Scottsdale, Arizona, was kind enough to write the foreword for Beauty from Afar. I found him on the web long before I asked him if he would do that. There are not many cosmetic surgeons in the United States who are openly admiring of the work and advances made in other countries.

Specifically, John has trained at one of the most renowned cosmetic surgery facilities in Brazil He talks about how that has influenced his work in today’s segment:

Chapter 2 Page 7 | The Best of Both Worlds

I’m grateful to have had the benefit of John’s point of view and experience.

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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One of the great things about being a writer is that it gives one lots of opportunities to talk to interesting people one would otherwise never have met. For me, over the past 25 or so years, this has meant chatting with people ranging from accused murderers to U.S. Senators, the infamous and the celebrated.

For Beauty from Afar, I got to talk to doctors and surgeons. Lots of them. And they are a fascinating bunch. In today’s segment:

Chapter 2 Page 6 | Point, Counterpoint

… I compared and contrasted statements from two doctors, one from Texas and the other from Brazil, both renowned plastic and cosmetic surgeons.

I remember thinking that Dr. Rod Rohrich of Texas probably wanted to hang up on me while we were chatting on the phone and that I wouldn’t really have blamed him if he did. I was clearly writing something that was going to be at least somewhat at odds with his public pronouncements about going overseas for plastic surgery. I remain grateful that he took time to talk.

The Brazilian surgeon, Dr. Luiz Toledo, is now apparently working in Dubai! Links for both surgeons are provided in the segment.

The web site and staff of the International Society of Aesthetic and Plastic Surgeons (ISAPS) were both very helpful in my research. Sometime after Beauty from Afar came out, ISAPS published its own briefing paper on medical tourism which was rather less negative than the one put forth by the American Society of Plastic Surgeons.

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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Chapter 1 Page 7 | 100,000 Fellow Travelers — or More

(Author’s Note: The reader should be aware that the following numbers were calculated for 2004-2005. I do not claim they are representative for any other time. If I had to guess right now, in 2009, a time of global recession, I’d say that cosmetic surgery abroad might well be in the doldrums, just as it is within individual countries such as the United States.)

Today, with access to the Internet, the millions of prospective and actual cosmetic surgery patients in the United States can be remarkably well-informed before ever setting foot in a surgeon’s office. They are familiar with the procedures;  they’ve seen before-and-after pictures. The Internet and television have supplemented traditional word-of-mouth marketing of cosmetic surgery, and many U.S. doctors build their practices substantially through their Web sites.

But the Internet also opened up this vast U.S. market to aesthetic and cosmetic surgeons abroad.  And in increasing numbers, they are going after the U.S. market directly.

How many people from the United States are actually going south of the border (or anywhere else) to save money on liposuction, face-lifts, tummy tucks and the like? In recent news stories, the conventional line, almost to the point of cliche, was  “no one knows.” I have been told by several U.S. surgeons who cared to speculate that the numbers are negligible;  however, these have been the same surgeons who are most concerned about (or opposed to) people going overseas for surgery. Some doctors and journalists have guessed it to be in the  “low thousands”.

This is almost certainly bad guesswork, though it all depends on who and how one wishes to count.  Consider, and do the arithmetic along with me: Costa Rica, the “Beverly Hills of Central America,”  where there are perhaps 35 to 40 cosmetic surgeons who work primarily on patients from the United States. The best and most experienced are busy constantly, and some will do several surgeries a day. These board-certified surgeons each handle as many as 40 to 50 U.S. patients a month.  Even accounting for slackers, one cannot put the annual total at less than 5,000. It could be double that or more.  A prominent surgeon I know puts the total at more than 20,000.

One can speculate conservatively that a similar number of people visit Costa Rica for just dental work, as I did. There are a lot more dentists,  according to one surgeon, and there is some overlap, as many patients will have both plastic surgery and dental work done on the same trip. Many procedures are also done by non- board- certified physicians and surgeons.

Brazil,  a mecca for cosmetic and plastic surgery with a reputation that precedes and, in much of the world, overshadows that of Beverly Hills:  There are more than a million Brazilian-Americans in the United States. The population has tripled since 1990.  Perhaps there was a time when only hundreds or a few thousand U.S. residents traveled to Brazil for cosmetic surgery annually, but that time is past. Brazilian surgeons are polishing their English and their Web sites and building new facilities. Count another 10,000 and growing.

Mexico, the most telling of all: There, more than 900 board-certified plastic and cosmetic surgeons ply their trade. Despite a stream of cautionary and negative news reports about the practice through the years, undoubtedly far more U.S. residents visit Mexico for cosmetic and plastic surgery than any other country. There are more than 30 million Mexican-Americans in the United States, as a receptive base market. Mexican surgeons advertise in the United States and even visit our country regularly on marketing expeditions, mostly in the South and West. It is not reasonable to guess that “a few thousand” U.S. residents head for the border annually for cosmetic surgery. I venture an educated estimate that the number is at least 40,000.

Tourists seeking liposuction or face-lifts do not declare their intentions at the border, and I have run across only a few doctors and surgeons abroad who can give a good estimate of the number of U.S. patients they see themselves, let alone an aggregate number for their country.  But the number for Mexico adds up quickly. I’m told that perhaps half the doctors do little or no work on patients from the United States.  Still, if the other half averages two U.S. patients per week, the total would come to nearly 50,000. This does not account for cosmetic dental work or the number of patients who get cosmetic surgery from non-board-certified physicians.  It also ignores the fact that there are hundreds of thousands of U.S. citizens living in Mexico, perhaps as many as a million, who presumably are likely to seek medical care, including cosmetic surgery, from local doctors and surgeons.

The Dominican Republic, another medical tourism destination that has been vilified, more often than not, in the popular media in the United States:  There are approximately 60 busy cosmetic surgeons in and around the capitol, Santo Domingo. For many of them, more than half of their patients come from abroad, mostly from the United States. Moreover, there are more than a million Dominicans residing in the United States, at least 600,000 of them in the New York City metropolitan area alone.

Dominican surgeons travel to New York regularly to make presentations to prospective patients.  The prices of even the best, most-qualified surgeons in the Dominican Republic for common surgical procedures are 50 to 70 percent less than what is charged in the United States. Business is booming. It is not unreasonable to guess that board-certified plastic surgeons in the Dominican Republic, plus other doctors and surgeons who perform cosmetic procedures,  see at least 10,000 patients a year from the United States, not including dental patients.

The rest of the world: A “few thousand”  more from the United States travel to other Central and South American countries, all of which are represented in the United States by growing immigrant groups. Destinations in the Far East are growing in popularity;  Eastern Europe and South Africa are more popular with western Europeans as places to go than they are with Americans, but surgeons in those countries have only just begun competing for the huge North American market.  And Malaysia and Thailand are both increasingly popular destinations. Add another 10,000 to 20,000 to the total, easily.

I am comfortable, then, in conservatively guesstimating the number of U.S. citizens currently traveling abroad for plastic and cosmetic surgery at something in the high five figures, approaching 100,000. This would be about 5 percent of the 1.7 million estimated cosmetic surgeries performed in the United States.

I don’t have a similar feel for the total number of U.S. patients who go abroad for dental care, other than to suspect that it is similarly substantial. Certainly, at least a dozen major dental practices in Costa Rica thrive on serving the U.S. market.

An assertion that the number of U.S. residents, mostly women, who would travel abroad for cosmetic surgery might be rapidly approaching 100,000 annually, or even higher, will no doubt nettle some doctors and surgeons in the United States. Yet how are we to get a grip on the phenomenon (or “problem,”  if that is your point of view) if we do not attempt to get a handle on its size?  Until the last decade, the story of what is now called medical tourism was mostly about people in other countries coming to the United States for sophisticated medical treatment, if they could afford it. And the traffic has by no means completely reversed.  Many thousands of people still come to the United States for health care, including cosmetic surgery. Almost certainly, far more money comes into the United States from abroad to pay for medical care than leaves the country.

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Introduction Page 3 | Seeking Beauty from Afar: How I Got My Smile Back

A Nose Job in Iran?

I first focused on the bigger picture, which was plastic and cosmetic surgery in Costa Rica and elsewhere, and soon found myself swimming in a sea of Internet message boards. Mexico — was it safe? Had anyone been to Malaysia? Did South Africa make any sense at all? Why Spain for weight-loss surgery? Nose jobs in Iran, tummy tucks in Colombia, sexual reassignments in Thailand, new boobs in Brazil … it seemed that in every corner of the globe, plastic surgery was being performed for fees dramatically less than those charged by doctors in the United States and Europe, and it was even being done in places prospective patients could consider going to for a vacation.

Still, it was something one had to know about to find. It was a phenomenon, perhaps even a trend, but small — in fact tiny — when measured against the number of people who don’t leave the country to want cosmetic surgery. It didn’t even really have a name yet, though the mainstream media made periodic attempts to label it. “Lipotourism” was tried on for size (notably by The New York Times), but it didn’t really stick, describing, as it did, mostly a quick trip for fat suctioning and not much else. I’d run across “medical tourism” and used it once in an article, but it wasn’t in common usage. “Health tourism” was another borderline misnomer. As time passed, the term “medical tourism,” as uncomfortable as it is to some people, caught on.

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