Beauty from Afar

I’m back where I started this week — Prisma Dental in Costa Rica. Good times.

I’ve wondered if I’ll ever get around to posting the rest of Beauty from Afar online — seems I’ve been stuck in Chapter 5 since the invention of tooth paste — but if anything will get me motivated again, it’s visiting with my dentists Josef and Telma, still up to their wrists daily with dental implants and crowns and smile restorations and such. They’re great people and I’d love them even if they weren’t my dentists.

Maybe I’ll add some photos and video later in the week.

If anyone asks, I’ve recently moved to Brookfield, Conn., and am commuting part-time to a job in New York City …

Cosmetic surgery is not a commodity. All facelifts are not created equal. And “How much is a facelift in Mexico?” … or in California, or Costa Rica, or Malaysia is not, are not questions that have tidy, brisk answers. You pay for the experience of the surgeon. You pay for geography. You pay what the market will bear.

Chapter 4 Page 2 | Cosmetic Surgeries and Procedures

Despite the efforts of my editor to wring specifics from me on cosmetic surgery prices, I held to broad ranges when characterizing what cosmetic surgeons charge in different countries — or even within one country, or in your neighborhood. As such, the information I gathered in 2004-2005 is probably just about as relevant now as it was then. Surgery prices have no doubt risen for some, declined for some and stayed about the same for others. Fluctuations of the dollar and exchange rates have mostly been unfavorable for overseas surgeons who operate on U.S. residents — but not extraordinarily so.

There are some changes, surely … and I hope readers will enlighten me as we go.

Chapter 3 Page 5 | The Media Imprimatur

The media in the United States did not really discover medical tourism until 2004-05, and it was found in the Far East rather than in central and South America. It was Bumrungrad Hospital in Thailand and the Apollo Hospital Group in India and Penang Adventist Hospital in Malaysia that made 60 Minutes and the front pages of the Wall Street Journal and The New York Times, not the plucky surgeons and dentists of Costa Rica, Mexico, and Brazil — even though far more U.S. citizens were heading South for inexpensive medical and dental care and surgery than were heading to the Far East. There are a few good reasons for that, which I offer not as an apology for the media but as explanation:

1. The story wasn’t about cosmetic surgery, which, despite its popularity and the professionalism of its practitioners, doesn’t get the same treatment in the news as does “real” medicine. Cosmetic surgery news is fluffier, more frivolous, than open-heart surgery news. The international hospitals of the Far East, wisely, didn’t play up cosmetic surgery — though they do a lot of it. They played up cardiothoracic surgery, and their state-of-the-art technology and facilities, and thus were taken more seriously. For the first time, much was made of the fact that there is an estimated 42 million people in the United States who lack adequate medical insurance who could go out of the country to get treatment they could not otherwise afford.

2. The story was delivered in part as a business story with big dollar signs, the kind that gets attention from the media. India put a $2 billion sticker on medical tourism. As previously noted, Bumrungrad sees more than 350,000 patients a year.

3. The story was generated by big multipurpose hospitals, and supported by the tourism and economic development officials of their respective countries. This is the way countries in the Far East go after markets, and there is nothing in Central or South America to compare as yet.

As we move through the first decade of the 21st century, medical tourism is still both newly discovered and in transition. The tip of the iceberg remains elective medical care, mostly cosmetic surgery and dentistry; beneath the surface is the larger consumer health-care market of North America and Europe.

And the media is paying attention. In February 2006 a West Virginia state legislator introduced the first bill in the country providing for the outsourcing of medical care to foreign countries. In Chicago, Blue Cross/Blue Shield investigated and then approved payment for an insured child’s heart surgery in India. And when President Bush visited India for the first time in March 2006, the two countries released a statement pledging American support for Indian efforts to support medical tourism, saying there is “enormous potential for collaboration” in health tourism.

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Our little history lesson continues today with a segment about how a plastic surgeon in Costa Rica started marketing to the U.S. market in the early 1980s; and continues with a discussion of a somewhat prescient World Bank report on prospects for health tourism exports in the Caribbean.

Chapter 3 Page 3 | Build It, and They Will Come …

I thought I’d be sailing through Chapter 3 easily but have had a lot of reformatting to do from the version of Beauty from Afar from which I am working … which I have now realized is probably the penultimate digital copy. Aaaaiiieee! An alert reader, Debbie, caught a mistake the other day in which I had named someone other than Alexandre Dumas as author of The Three Musketeers. Fortunately, the error was fixed before the book was printed. I do remember how I felt when I found the mistake initially — after I’d “finished” writing the book and after it had been twice edited. I felt both as though I’d dodged a bullet and as though I was nearly too stupid to live.

There are a couple of minor errors in the paper version of Beauty from Afar. It is nice to have the opportunity to fix them.

I used to be appalled when I found typos or any kind of mistakes in books. How could it happen? Well — now I know the answer. It can happen in all sorts of ways. Human beings are involved. With Beauty from Afar, they mostly happened because I was allowed to fuss with and add things right up until the last second — as though we were producing a newspaper story instead of a book. Overall, I think the additions and last-minute changes made for a better book … but there is a tradeoff. Typos, however minor, are just disheartening.

Chapter 3 Page 3 | Build It, and They Will Come …

Arnoldo Fournier, M.D., a cosmetic surgeon in San Jose, Costa Rica, was one of the pioneers in marketing his services abroad. He came to Costa Rica in the early 1980s, fresh from his residency at St. Luke’s Hospital in New York, and was told that there was no demand for aesthetic procedures in Costa Rica.

Stubbornly, he stayed and went after the U.S. market. He placed his first ad in the Tico Times, the Central American country’s English-language daily; later, he turned to the flight magazines of the international airlines: LACSA, Eastern, Skyward and Passages among them.

By the 1990s,  Dr. Fournier and other Costa Rican cosmetic surgeons, dentists, and doctors thought they had a pretty good thing going. Costa Rica was beginning to prosper as a tourist destination and U.S. retirees were making the country their home in increasing numbers; the number of Americans desiring cosmetic surgery was starting to rachet up.

Prices for cosmetic surgery in Costa Rica then, as now, were much lower than in the United States. I received an e-mail in December of 2004 from a woman in Florida who had read what I had written about my own trip for dental work; she affectionately recalled going to see my dentist, “Dr. Telma,” in 1986. She wrote:

In 1986, Dr. Telma installed 13 crowns in my mouth for $1,200. At that time, if I had this work performed in the U.S., it would have cost about $4,000 to $6,000 … As she worked, Dr. Telma and I also had incredible intellectual discussions on the anthropology of Central American Indians, their bone structure and diet, and where they came from. Both she and her husband are very well educated in many other areas, and not just dentistry … I came across your article as I was searching the ‘Net for her services again. I need two crowns and some teeth bleaching, and a minor face lift, which I am going to coordinate and schedule this summer if possible.

So what was to become known later as medical tourism was already growing in Costa Rica in the 1980s and into the 1990s. In what was to prove to be a prescient report, the World Bank in September 1995 published a 52-page study on Prospects for Health Tourism Exports for the English-Speaking Caribbean. (2) It noted:

Direct patient care is the major health service exported by Costa Rica. In addition to plastic surgery, a full range of pediatric and adult services including high technology dependent procedures such as open heart surgery are exported. Costa Rica’s target markets for the export of health services are the United States, other Central American countries, Puerto Rico, Barbados, and other Caribbean nations, Colombia, Venezuela, Canada, and Spain.

The prescient part of the study identified the reasons why potential for further substantial growth existed in the Caribbean countries:

• Demographics in target markets (for example, aging post-war baby boomers who are concerned about physical appearance, semiretirement, full retirement and relaxation) will mean marked increases in demand for cosmetic surgery, spas, and retirement communities.
• The growing affluent class of baby boomers may be less price sensitive and more sensitive to other aspects of the marketing mix (for example, location and confidentiality.)
• Lifestyles in Europe and North America increase the demand for services such as spas, fitness centers, cosmetic work, or addiction treatment centers.
• Waiting time for procedures in the United Kingdom and, to a lesser extent, in Canada encourages the search for outside health services.
• A large portion of the U.S. population is uninsured or underinsured.
• Private insurance does not cover selected treatments.
• Operations in Caribbean regions appeal to doctors from target markets that enjoy visiting the region, which could facilitate strategic alliances and capital investment.
• Lifestyle health-related problems in the target markets are similar to those among people in the Caribbean, and quality health and social marketing materials could be exported to these markets.

“The U.S .market is most apt to offer opportunities to the Caribbean because it has a large uninsured and underinsured population, it has very high prices, and it is geographically close to the Caribbean,” the report stated. “Moreover, the U.S. system is more fragmented and less controlled than health sectors in other industrialized countries. As a result, the U.S. market has multiple avenues of entry.”

The report also summed up the challenges facing countries going after the health tourism market as well, among them that:

• U.S. medical doctors act as “gatekeepers” for the U.S. health-care system and would not want to lose patients to the Caribbean market.
• Questions about quality of care in the Caribbean will exist in consumers minds and will be difficult to overcome.
• Neighboring countries in Latin America could provide care at lower cost, as could countries in Eastern Europe.

Other than leaving out the entry of Asian, Middle Eastern or African nations into the market, the World Bank study was a blueprint for medical tourism for the next decade for anyone who cared to follow it. However, it made no particular impact then that I can discover now. What it stated was already obvious to pioneers in Costa Rica and elsewhere, but it took years for much of the world to begin to notice. The third and final precondition for medical tourism to become a globe-straddling business was that people had to know about it; it had to be marketed to a broader audience, somehow. The Internet came along at just about the right time.

(2) Prospects for Health Tourism Exports for the English-Speaking  Caribbean by Maggie Huff-Rousselle, Carol S. Shepherd, Robert Cushman, John Imrie, Stanley Lalta. World Bank, Washington, D.C.; Social Sectors Development Strategies, Inc. September 1995.

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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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Today’s so-called “page” is just three paragraphs. That is the way it worked out with the subheads from the original book.

Chapter 2 Page 8 | If You Can’t Beat Them …

I excerpted this aside from a lengthier interview with Oscar Suarez, M.D. in his office at CIMA Hospital, and I quote him more extensively later in the book. I don’t know if he is still head of the Department of Plastic Surgery at CIMA but it is evident that his practice is thriving. That is one of the problems with including official titles in books — people move on from where they were.

When I first walked into the waiting area of Dr. Suarez’s office, his assistant asked me what procedures I was interested in … and it was the first time anyone ever suggested I might need (or at least want) cosmetic surgery. I’m sure it was SOP for the office and no psychological harm was intended. For the record — at 53, I’m unmodified, other than my teeth.

Chapter 2 Page 8 | If You Can’t Beat Them …

Oscar Suarez, M.D., is head of the Department of Plastic Surgery at CIMA Hospital in San Jose, Costa Rica. CIMA is a modern, private facility where a number of Costa Rican surgeons cater primarily to patients from the United States.

“The surgeons in the United States, the ones I talk to, are of two minds about medical tourism,” Dr. Suarez said in an interview. “Some are against it. And others, they want to be part of it.” Dr. Suarez said he has been contacted by a number of peers in the United States who are interested in partnerships or opening facilities in Costa Rica.

That a patient can find experienced and talented cosmetic and aesthetic surgeons in a number of countries around the world is not a matter in serious dispute. Surgeons can disagree as to the risks involved in traveling and as to the difficulty of choosing a good surgeon. In the end, however, those are considerations for individual patients to weigh. Prominent, qualified, and experienced surgeons from all countries emphatically counsel patients that they should not choose a surgeon based on price alone.

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Chapter 1 Page 8 | Tip of the Iceberg — and a Trend

Global competition for health-care dollars is relatively new. The balance is shifting. From the perspective of many health-care professionals in the United States, Canada, and the nations of western European, this is unsettling. It highlights some of the deficiencies in western medical systems: In the United States, high costs and a high number of uninsured; and in Canada and western Europe, long waits and similarly high costs for elective procedures. At one time, only a small number of people from the developed nations went abroad for inexpensive plastic surgery, while a large number of wealthy people from countries with lesser medical care came to the West for advanced care, treatment, and surgery. The estimated 100,000 people (and growing) who now leave the United States annually for plastic surgery only represents the tip of an iceberg for medical tourism as big business.

There are already large success stories that have legitimized this point of view. Bumrungrad International Hospital in Bangkok, Thailand, is the best known; in 2004 it boasted treating more than 350,000 patients from 150 countries. India is hurrying in the same direction, projecting that medical tourism could be a $2.2 billion business by 2012. Put this way, it sounds huge and economically threatening to the United States and its medical-care system. One can imagine that 10 years from now, the lion’s share of the U.S. cosmetic and other elective surgery businesses will be offshore; that U.S. insurers and Health Maintenance Organizations (HMOs) will be putting a hefty percentage of nonemergency-care patients with expensive treatment or surgical needs on airplanes out of the country rather than sending them to local doctors, hospitals, and surgeons. This is a highly exaggerated scenario.

Medical tourism, as such, does not represent a substantial immediate threat to the medical system of the United States, or any other country for that matter. What, after all, is a few billion dollars compared to the $1.7 trillion spent on health care in the United States each year? The billions represent a small shift in revenues in a worldwide multi-trillion dollar health-care system. By serving the uninsured and the underinsured in the United States and by providing an alternative to long waits for treatment or surgery in Canada and western Europe, medical tourism in a sense is augmenting the health-care systems of developed countries, filling and bridging gaps, providing another safety net.

As for aesthetic and cosmetic surgery — the “tip of the iceberg” for the medical tourism phenomenon — overseas surgeons are filling a need. Time and time again, I have heard from surgeons in Mexico, Brazil, Costa Rica, and the Dominican Republic: We are not taking patients away from U.S. plastic surgeons. Our patients come to us because they cannot afford U.S. prices. If not for us, they would not have surgery at all.

There are many doctors and surgeons in the United States who would prefer that medical tourism just go away. And cosmetic surgeons, personally and through their membership organizations, have thus far expressed most of the public concern and opposition. This is understandable, but there are degrees of opposition, and one would be mistaken to think that all are of the same mind. It is reasonable to suspect that, as time goes on, more medical professionals in the United States will take a less U.S.-centric position and, generally accept that they have an international community of peers.

Just a few months after I returned from my dentistry adventure in Costa Rica, I had an appointment with my ophthalmologist. I am extremely nearsighted and have been from an early age. I’ve worn contact lenses for 36 years, which seems an impossibly long time. In the last several years, my eyes changed such that I was perilously close to requiring bifocals or, as an alternative, reading glasses to wear with my contact lenses. My eye doctor, on this visit, told me that I was an excellent candidate for Lasik eye surgery. I knew what Lasik was, certainly. I knew a lot about it. What lifelong myopic didn’t read up on that when it came out? But I had never before been told I was a good candidate for it.

“It’s improved a great deal in the last two years,” she told me, in response to my questioning about the procedure’s reliability and success rate. “They’ve refined it. We probably won’t see it get much better than it is right now, not anytime soon.”

I knew that Lasik surgery costs more if one is severely nearsighted. She nodded when I guessed the cost. “Yes, you’d probably be paying around $4,000.”

I hesitated, and then told her my Costa Rica story, the short version. And I asked, point blank if she would help and support me if I chose to get Lasik surgery done overseas? Would she work with the foreign doctor, help me get the best care I could? Because I didn’t have $4,000 for Lasik surgery.

She looked me right in the eye.

“Absolutely,” she responded, firmly, surprising me a little. And we had a long talk about where would be the best place to go. My ophthalmologist had a slight preference for India, though we agreed, laughing, that as a second-generation Indian, she perhaps has a prejudice.

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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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