Beauty from Afar

Chapter 2 Page 4 | Sticks and Stones

On one side, we have U.S. doctors and public officials issuing a very real warning: don’t go out of the country for plastic surgery, especially to the Dominican Republic. On the other side, we have the trained medical establishment of the Dominican Republic arguing that they have been unfairly vilified for competitive reasons and with ignorance of the true state of affairs in the country. It would probably pass for journalistic fairness these days if I simply let representatives of the two views slug it out. I have certainly talked to earnest, well-spoken, successful, well-known surgeons who can do just that.

Lost in the shouting, likely, would be the common ground. I could choose a top, board-certified cosmetic surgeon in the United States and a top, board-certified surgeon in the Dominican Republic or another country and wager that they would agree on the following:

• Schooling, training, and board certification processes are substantially similar. In fact, they are so similar among the United States and other countries with modern medical schools, teaching hospitals, and national peer oversight that a discussion of the differences would only be of academic interest.
• There are similar personal standards for operating facilities, regardless of what national board is responsible for certifying the facilities.
• No patient should undergo a cosmetic procedure without fully understanding the risks and having a realistic estimation of the outcome.
• Cosmetic and aesthetic surgery should only be performed by fully trained, experienced professionals such as themselves.

It is easy to browse the World Wide Web and find successful, board-certified plastic and cosmetic surgeons with lengthy and impressive resumes and glowing recommendations from grateful patients. The only significant difference you will find among the surgeons are geographical location — and price. Both are important factors to a patient.

The attention the don’t-go-to-the-Dominican-Republic-for-cosmetic-surgery scare drew in 2004 and 2005 shows that there is controversy and confusion about medical tourism, in general, and cosmetic surgery, in particular.  The story also added credence to the notion that traveling out of the country for cosmetic surgery is a phenomenon, not an aberration. A dozen or a few dozen serious infections, while disastrous for the individual patients and alarming and confounding to their doctors, is completely unsurprising given the number of surgeries performed. In fact, one can be reasonably sure that there have been quite a few more infections than those reported and that there are many more patients who have been less than satisfied with their results.

Choosing even the best, most experienced, and most expensive cosmetic surgeon, whether it be in the United States or abroad, is no guarantee that a patient will heal perfectly. Certainly it must cross the minds of any person who elects to have cosmetic surgery that there is at least a small chance that he or she will be disfigured or will die. There is a somewhat greater risk that someone will simply be dissatisfied, to some degree, with the results. Top U.S. plastic surgeons complain that too much of their time is spent fixing the poor work of others from the United States and abroad. However, top surgeons in other countries make the same complaint.

The bottom line is that the Dominican Republic scare story made it manifestly clear just how price-sensitive the cosmetic surgery consumer market is. In the minds of an increasing number of consumers, the difference between a $3,000 tummy tuck overseas and a $7,000 one in the United States is, simply, $4,000; and the $4,000 represents not a cost of quality assurance but a cost some people are either unwilling or unable to bear. The fact that the story did not hurt the cosmetic surgery business in the Dominican Republic much, if at all, says that traveling abroad for inexpensive cosmetic surgery is not a fad any more than cosmetic surgery itself is. If the price is right, Americans will shoulder some inconvenience, bear some uncertainty, and weigh risk when considering their medical and health-care options. They are doing it for cosmetic surgery. In lesser but growing numbers, they are doing it for other kinds of medical care, too.

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Chapter 2 Page 3 | A warning lives on, mostly unheeded

The costs for common cosmetic surgery procedures in the Dominican Republic are roughly 40 to 70 percent less than they are in the United States. Dominican surgeons, particularly members of the Society of Plastic Surgery, felt that they were under assault by the U.S. media, by U.S. doctors, and by U.S. politicians because of their success in attracting U.S. patients. They thought that their skill and medical facilities had been unfairly maligned.

Their suspicions were raised by the fact that their statement went unreported in The New York Times or anywhere in the United States and that the initial story lived on in news releases and through references in other stories. As of January 2006, the U.S. State Department was still posting a warning on its travel advisory for the Dominican Republic:

The U.S. Embassy in Santo Domingo and the U.S. Centers for Disease Control and Prevention are aware of several cases in which U.S. citizens experienced serious complications or died following elective (cosmetic) surgery in the Dominican Republic. The CDC’s Web site contains further information for all patients seeking elective surgery overseas at http://www.cdc.gov/travel/other/elective_surgery_2004.htm.

Patients considering travel to the Dominican Republic for cosmetic surgery may also wish to contact the Dominican Society of Plastic Surgery (tel. 809-688-8451) to verify the training, qualifications, and reputation of specific doctors.

A similar report posted on the CDC’s Web site had been taken down months before, but the scare lived on. I assumed that business for plastic surgeons in the Dominican Republic had to have gone down the tubes. Negative publicity is bad enough when it involves a single doctor but the Times’ story was directed at the cosmetic surgeons and doctors of an entire country! What damage did it do to the country’s cosmetic tourism business? Surely, I thought, it had slowed to a trickle.

Not so.

If anything, business is better, Roberto Guerrero, M.D., of Santo Domingo told me a year after the story was published. Dr. Guerrero is a plastic surgeon who trained under Brazil’s Ivo Pitanguy, M.D.; it is a credential most U.S. plastic surgeons would love to have. “People heard more about us, about what we do. If anything, the story helped us.”

Dr. Guerrero, in a lengthy phone interview, defended the quality of surgery and the facilities available in the Dominican Republic. There are roughly 60 board-certified surgeons, and the requirements for certification are every bit as stringent as in the United States.

“The infections — they can happen anywhere. They happen in the U.S.,” he said. “We have doctors here who are not board-certified, who do cosmetic procedures … and you have that in the U.S. as well.”

But by then, Dr. Guerrero was telling me what I already knew — that there are supremely talented cosmetic and aesthetic surgeons working in the Dominican Republic in modern facilities, just as there are in Brazil, Costa Rica, Argentina, Mexico, and, of course, in the United States, and around the rest of the world. Like one woman told the Times: “There are good and bad doctors everywhere.”

(Author’s note: The CDC Internet page cited  above no longer exists in 2009. However, the State Department warning about cosmetic surgery is still up, here; and the dated CDC report lives on, here — five years later.  My guess is that it is a bureaucratic nightmare to get the State Department to remove such information.)

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Chapter 1 Page 6 | Dear Dr. Rubinstein …

When I contemplated traveling abroad for dental work, it took me a month of research on the Internet before I was finally ready to make a direct inquiry. A month — and that was just to feel confident about choosing a country from which I would select a dentist! I picked Costa Rica over Thailand because proximity to the United States played a big role in my thinking. “I don’t want to go too far if I don’t have to.” This, from someone who had thought nothing of taking off for Africa for a year, at age 20. (Which is a whole ‘nuther story.)

There was a wealth of information available on dentists and dentistry in Costa Rica at the time, more so than anyplace else (except for the United States, of course).  I wrote to the aforementioned Telma Rubinstein, D.D.S., of Prisma Dental in San Jose, Costa Rica, on February 16, 2004.  Prisma had a Web site.  I confess I chose them as first contact because they had a female dentist. I felt sure I would have a lot of questions,  and my instinct was that a woman would be more likely to be patient with me.

Dear Dr. Rubinstein,

I am writing to inquire about having cosmetic dental work done at your practice in Costa Rica.

My dentist here in Connecticut, two years ago, had taken a mold of my bite and recommended, as I recall, eight or 12 porcelain crowns. I must say I concur with his opinion. My teeth are quite worn and small, at 47 years of age. I also have a badly chipped front tooth. I could send you digital photographs, if you’d prefer to see that way.

My dental insurance at the time would not cover any of the considerable fee, however. I now find myself without dental insurance at all, but I recently heard that practices such as yours could do a fine job on the work I require at a significant savings. What can you tell me beyond what I have read on the Internet? How would we proceed?

Thank you for your time,

Jeff Schult

I never had to write to another dentist in Costa Rica or elsewhere. During the next 6 weeks, I peppered Telma, as she asked me to call her, with more than 20 e-mails filled with questions about her credentials and experience,  my teeth, prices, travel and accommodations, and Costa Rica in general, and she patiently answered every one.

Still, I didn’t really make up my mind until after I asked her if she had any problems with my writing a magazine article about my experience.  She had no qualms at all, and I took that as a sign of her complete confidence in her ability. I realized that I already knew more about Telma Rubinstein than I had ever bothered finding out about any doctor or dentist who had treated me in the United States.  Later, I felt kind of bad about having been so difficult.  “I put you through the wringer,”  I told her when we finally met. She laughed. I had been easy, she said, compared to many of her other prospective patients from the United States: “Some of them, Jeff, they ask me so many questions that I feel I have been stripped naked!” Since then, I have heard similar stories from doctors, dentists, and surgeons around the world who treat patients from the United States.

As I’ve already stated,  I believe that the United States has the highest quality of medical care in the world, the most and the best medical facilities, the highest level of technology, and the most stringent regulations and standards. Does that mean that all doctors and dentists and surgeons in the United States are better than all of their peers abroad, or even that most of them are?  I do not think even the most xenophobic member of the American Medical Association (AMA) would dare make such an assertion in intelligent company.  Even the most vociferous critics of medical tourism acknowledge that there are many fine doctors, surgeons, and dentists around the world working in facilities that are as modern as anything in the United States.

But the official party line of the medical establishment in the United States is:  Traveling abroad for surgery is generally far more risky than having surgery in the United States. Bad things are far more likely to happen. You shouldn’t do it.

The recent history of medical tourism in the United States suggests that more and more prospective patients for elective surgery, particularly candidates for cosmetic and plastic surgery, are rejecting the medical establishment’s No. 1 considered wisdom in this matter.  By far, the No. 1 reason they are doing so is cost. Aesthetic and cosmetic surgeries are elective services, paid for out-of-pocket by patients. Wealthy patients are not so price-sensitive, but procedures are no longer for just the well-to-do.

The demand for aesthetic and plastic surgery has skyrocketed in the United States and around the world.  U.S. surgeons performed three times more face-lifts in 2004 than in 1992;  nearly eight times as many people had liposuction. (5) A whole new business in so-called minimally invasive procedures (like Botox and injectible fillers) was born in the space of a few years. In 2004, U.S. cosmetic plastic surgeons performed more than 9.2 million separate procedures.  The most visible sign of the broad acceptance of aesthetic and cosmetic surgery in mainstream society was the emergence of several popular (and controversial) reality television shows such as Dr. 90210, The Swan, and Extreme Makeover. The Swan and Extreme Makeover were short-lived, but that they made it to television at all was a sure sign that plastic surgery is no longer seen as just for the affluent.  Americans of more modest means also want to look good — but price matters.

(5) American Society of Plastic Surgeons Statistics. at www.plasticsurgery.org.

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