Beauty from Afar

Chapter 4 Page 1 | You’re Going Abroad for…What!?

The most common cosmetic and other surgical procedures that lure people overseas

In more than a year of travel, interviewing, and reading, I have run across but one example of a medical procedure for which demand has declined overseas because prices in the United States became more competitive.

“We don’t do so many hair transplants as we used to,” commented Joseph Cohen, M.D., sitting in his office at the Rosenstock-Lieberman Center for Cosmetic Plastic Surgery in San Jose, Costa Rica. “The price came down in the States; there is not so much of a difference anymore. So people don’t come to us for that as much.”

Dr. Cohen, who did his undergraduate work in California and his residency in general surgery in Pennsylvania, also told me that if he needed heart surgery, he would prefer to be in one of the top hospitals in the United States. Not that there are not fine heart surgeons in Costa Rica; but he would have a preference for the United States: “They have the most experience and that’s what you want,” he said.

What procedures do people go overseas for, and why?

As of now, inexpensive cosmetic surgery and dentistry is the leading edge of medical tourism, at least as far as North Americans and Europeans are concerned. Weight loss surgery (WLS) of various kinds for the morbidly obese is also gaining in popularity, though some insurance plans in the United States provide coverage for that. Patients go abroad for every conceivable kind of medical care if the cost savings justifies the inconvenience and any perceived risk.

Of course, patients who are covered by insurance in the United States elect to have their surgeries and procedures done in the United States for the obvious reason that they will no longer be saving money by going outside of the country. However, there are exceptions. In some cases, patients prefer going out of the country because a foreign doctor or surgeon is renowned for his or her expertise in a particular procedure. Insurance companies, includings HMOs, have been known in certain cases to treat out-of-country care no differently than they treat out-of-network care in the United States. But this is something you need to check beforehand.

A more general exception is dental work. Most dental insurance plans in the United States effectively exclude major cosmetic work, either by way of defining what is covered, or effectively, by capping the amount of coverage annually or by procedure. Insured dental patients may have some minimal reimbursement difference to factor into their decision as to whether to go abroad or not, but in the case of major work —  implants or full-mouth reconstruction  — the savings for going overseas remains substantial and a compelling reason to consider it as an option.

In general, plastic surgeons in all countries perform a variety of procedures and services. Botox, facial “fillers” for wrinkles, lip augmentation, permanent makeup, and the like are all available around the world and are generally less expensive than in the United States. Many patients who go out of the country for more costly procedures will have additional procedures done on the trip as well, but it makes little sense to go to the expense of traveling if one is only seeking relatively low-cost, non-invasive procedures.

This chapter offers a rundown of some of the more common elective procedures for which people are willing to travel overseas to save money. Be forewarned that the prices cited are estimations and, depending on the surgeon, place, and time, can be more or even less than the ranges given. I attempted to be both cautious and reasonable in checking costs.

Prospective patients should remember that surgeons have varying prices for many reasons and that important among those reasons are experience and reputation for quality. Surgeons in less-developed countries generally have a lower price structure overall because their costs are substantially lower than those in the United States or Western Europe.

Another important consideration within the following summary is that not all surgeons define the same procedures exactly the same way. A facelift to one may be just the centerpiece of several procedures, each with a price that may be necessary to achieve the patient’s desired result (for example, facelift, plus facial liposuction, neck or chin lift and work), while another may include several procedures as part of “just a facelift.” Also, some surgeons will offer discounts for patients who undergo multiple procedures at the same time, as in so-called extreme makeovers.

When considering prices, prospective patients have to figure out and factor in all travel costs, which can also vary substantially.

For my own part, I did not choose the least-expensive dentists in the world, or even in Costa Rica. I first satisfied myself as to the quality of care I would receive from a particular dentist. I could have “shopped” more extensively but decided against it in the end. I knew that my savings would be substantial when measured against what I could expect to pay in the United States, and that was good enough for me. I saved at least $10,000, and perhaps I could have saved more; but I was comfortable with my choice.

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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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When it come to writing about places to which I have traveled, I have almost always chosen to write about the people I encounter and what it is like to be *me* when I travel. This is perhaps remarkably egocentric, yet I don’t see an honest way out of it. People can have wildly different experiences from a trip that is supposed to be more or less the same for anyone. I imagine that most people have very similar trips to DisneyWorld, for example. Yet my first visit there was on a belated honeymoon, nearly a quarter of a century ago; and my strongest recollection of the trip is a fabulously nonsensical fight I had with my then-wife over a game of miniature golf. This is not Disney’s fault; for all that they try to homogenize the American Vacation Experience, not everyone leaves with the intended memories.

Anyway —  I tried to make Beauty from Afar as much a book about compelling personal stories as it is a general guide to traveling overseas for cosmetic surgery, dentistry and medical care. So Chapter 1 starts out at a breakfast table at Las Cumbres Inn in Costa Rica, with patients sharing experiences, before I head in to Prisma Dental for a long second day with my mouth open.

Chapter 1 | Medical Tourism: Here, There and Everywhere

We’re up to Page 23 of the actual book, out of 220.

Introduction Page 2 | Seeking Beauty from Afar: How I Got My Smile Back

Jurassic Park It’s Not …

I remember what I had known about Costa Rica before I had started thinking of it as a place where I might get fine dental work done inexpensively.  Not a lot — but perhaps about as much as did my friend.  In fact, I am somewhat embarrassed to admit that I had not been 100 percent sure that Costa Rica was not an island, though I vaguely recalled that Costa Rica was somehow prominent in the 1991 bestseller, Jurassic Park.  I had to look it up. Michael Crichton’s ill-fated island was located off the coast of Costa Rica.  It is hardly a friendly reference point for a potential visitor.  In fact, it seemed to cause a little embarrassment when I mentioned it to a few Costa Ricans, as though they worry that North Americans might actually fear that there are T-Rexes and raptors in the outskirts of San Jose. But in the book, there is a casual mention of Costa Rica as a destination for those interested in having cosmetic surgery.

“Bowman, a thirty-six-year-old real estate developer from Dallas, had come to Costa Rica with his wife and daughter for a two-week holiday. The trip had actually been his wife’s idea; for weeks Ellen had filled his ear about the wonderful national parks of Costa Rica, and how good it would be for Tina to see them. Then, when they had arrived, it turned out that Ellen had an appointment to see a plastic surgeon in San Jose. That was the first Mike Bowman had heard about the excellent and inexpensive plastic surgery available in Costa Rica, and all the luxurious private clinics in San Jose.”

This, in 1991! I asked Michael Crichton, through his publicist, how he had come to include this aside. Though Jurassic Park is, of course, fiction, it seemed unlikely that the author would have wholly invented his characterization of Costa Rica. The response I received was that it was a long time ago; Crichton didn?t remember how he had come to include the passage. In any case, I felt as though I was more than a dozen years late to a party. I found out later that Costa Rican plastic surgeons have been catering to U.S. patients since at least the late 1970s. Who knew?  Lots of people, obviously; and at the same time, hardly anyone.

“We can’t say it’s a new thing,” I told my editor at Northeast, Stephanie Summers. “It?s been going on for a long time.” She was unimpressed.  “It’s new to our readers,” she said.

And it was.  Months after the story ran I was still getting e-mail. I put the article online, more or less as a roadmap for others who might want to think about undertaking a similar journey. I thought — there’s a book in all this. And there was. Dentistry in Costa Rica barely touched the surface of the cosmetic work being done outside the United States — the same or comparable quality, just for a lot less money.

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(9-15-09) added original Table of Contents

(9-14-09) Since it is increasingly apparent that physical copies of Beauty from Afar are becoming more scarce, I’m commencing to put the text online. Like, starting now, really.

I do not yet have pretty e-books made up. I’m working from an ugly Acrobat document I managed to make out of the original Quark document of the book that I wheedled away from my publisher in 2006. I don’t even know how I managed to get that far, since neither version of Quark I have will open the publisher’s file now. InDesign won’t do it either. If someone with a Mac and Quark 6 or so wants to see if they can help me out with a conversion … well, I’d be grateful.

Meantime, I’m pulling the text out and pasting it to a text file that will eventually work great as a flat format e-book. And, as I go, I’ll post pages. Today, we have the original author’s note and the foreword.

That’s the cover of the book, at right. I didn’t pick it. And, in fact, I’m still a little embarrassed by it, for obvious reasons. I’ve been told by a lot of people I shouldn’t be and they’re probably right. “Sex sells.” What’s to be embarrassed by?

Still …

Here is the never-before-published cover sheet I did for the original book proposal. You can tell I had a different notion of what the book was about.