Beauty from Afar

I still don’t know the source of the infections that caused the Center for Disease Control and the U.S. State Department to warn against cosmetic surgery in the Dominican Republic in 2004. I don’t know the names of the patients; I think it would be very hard to find those out. Their privacy would be protected by both the CDC and their doctors.

But there has been no such outbreak since that time, or I almost certainly would have heard about it. In:

Chapter 2 Page 4 | Sticks and Stones

… I kind of closed the circle on that story, as much as I could. Good doctors and surgeons everywhere agree on fundamental practices that impact patient safety. Surgery, almost by definition, is not 100 percent safe. Even good surgeons can have poor or even disastrous results on occasion, despite every effort to reduce the likelihood to zero.

Patients take risks. They sign a lot of papers before undergoing surgery in which they acknowledge risk. They do their own part to minimize risk by informing themselves about what to expect; by preparing their minds and bodies for surgery; and by choosing a good doctor and surgeon. That is a lot of what Beauty from Afar was (and is) about: patient choices, and how to make good ones. I included the lengthy segments about the Dominican Republic because the story illustrates so many aspects of medical travel. In the end, I draw a different conclusion than did New York City officials, or the U.S. news media. I would not tell anyone not to go to a particular country for surgery. Tens, even hundreds of thousands of patients have gone to the Dominican Republic … or to Mexico, Costa Rica, Brazil, Columbia, Thailand, Malaysia, etc.  for cosmetic surgery in the last five years and have been happy with the results and the price.

And a few have gone and have been unhappy, or worse.

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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Today, we continue the short saga of the U.S. and its media vs. cosmetic surgery in the Dominican Republic in 2004.

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

When I was writing Beauty from Afar, I remember being somewhat concerned about the fact that I was saying that the U.S. State Department was still warning in 2006 against having cosmetic surgery in the Dominican Republic based on a 2004 CDC report … surely, I thought, that warning will be taken down at some point in time.I was careful to note the time element.

I needn’t have been concerned on that count, anyway. The warning is still up in 2009.

In this passage, I quote Dr. Roberto Guerrero. I remember the conversation well and regret that I never have gotten to meet him in person. His web site isn’t in the book. I see he can now be found at PlastiCenter: New Concepts in Plastic Surgery.

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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News coverage can make — or break — the medical travel business of a doctor, a hospital or even a country. Reports of poor health care abroad — or reports of bad results in otherwise good health care — can have a significant impact on medical travel decisions.

One can imagine that the news media coverage in 2004 of illnesses allegedly connected to cosmetic surgery done in the Dominican Republic might have led to a significant decline in the number of people going to that country for procedures.

Chapter 2 Page 2 | News Gets Around

As I  have noted, however, the story was short-lived and in this particular case, may have done more to publicize the availability of inexpensive cosmetic surgery in the Dominican Republic than it did to convince prospective patients of danger! More on that in the next post …

Chapter 2 Page 2 | News Gets Around

The story certainly got my attention; At the time, I was in the early stages of research for this book. And I was appalled. The Dominican Republic was not on my short list of countries to write about. In fact, I knew next to nothing about it.  “I guess I won’t be suggesting people go there for surgery,” I said to a friend. “People really will think I’m crazy.”

I waited for a follow-up story …  that never came. No lipo-tourism sales network was closed down or even investigated; no beauty parlor operators were arrested. The story vanished from the news. It only resurfaced as a reference point anytime a reporter did a story about traveling abroad for plastic surgery.

It wasn’t until a year later that I had the opportunity to personally talk to some Dominican doctors about the story, and find out that the Dominican Society of Plastic Surgery had issued a statement refuting the allegations. It never made it into the New York Times. The only reference I could find was reported in the Dominican Republic news. I was able to find it on a Dominican Web site:

The president of the Dominican Society of Plastic Surgery, Julio Pena Encarnacion, says that there has not been a single case of skin infection in the Dominican Republic similar to the 11 patients from New York who have lodged complaints after having operations here. The cases, which are being investigated by a team of plastic surgeons and Public Health Ministry officials, resulted in abscesses and cutaneous [skin] rashes near the area on which the surgery was performed. Pena Encarnacion said that the cause of the infection could be related to the water used, the sterilization of the instruments, or the piercings or lesions resulting from treatments carried out in beauty parlors. Yesterday, anesthesiologist Ariel Perez said the reports are due to fear of competition in the plastic surgery field in the Dominican Republic. Pena was cautious when referring to the competitive zeal as being the motive for the grievances. As reported in [the newspaper] Diario Libree, he said:

“It could be a result of the competition because of the professional quality services being rendered here, but in the end, each patient opts for the physician they consider to be the most trustworthy.”

Pena mentioned that it is not only Dominicans living abroad who travel to their home country to have surgery, but also foreigners from the United States, Puerto Rico, Venezuela,  St. Thomas,  Argentina,  Switzerland and the Netherlands.

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There are occasions in Beauty from Afar when I use contemporaneous news reporting about medical travel and tourism as kind of a foil: “This is what was reported,” vs. “This is what actually happened,” or “This is what they didn’t say.”

As someone who has spent a lot of years in a newsroom, I didn’t take any fiendish glee in pointing out the shortcomings of reporting. I am only too aware of how difficult the job can be and how hard it is to do well. The anecdote with which I lead in Chapter 2, about a brief panic in New York City over mysterious illnesses attributed to botched cosmetic surgery done in the Dominican Republic, is a case in point.

Chapter 2 Page 1 | Comparing Quality, Comparing Costs

You’ll have to stop back to get the rest of the story, since I’m taking this a day at a time. But I recall that I managed to track down the reporter who did the original story — which was fine, as far as it went. But as I pointed out, the story cried out for a follow-up that never came. (Until Beauty from Afar.) The reporter was an intern, gone by the end of the summer. No one else followed up. That kind of thing happens a lot in journalism. Even at The New York Times.

Chapter 2 Page 1 | Comparing Quality, Comparing Costs

Why care abroad is just as good as in the United States, and
why it is so much less expensive than in the United States and Europe

If ever there was a day that America was going to be persuaded that traveling abroad for inexpensive plastic surgery is foolhardy and dangerous, it was July 2, 2004. On that day a story about cosmetic surgery overseas that came out of a news conference called by the city of New York made the front page of The New York Times; it subsequently made every major newscast, in fact. “A Warning on Cut-Rate Surgery Abroad”, was The Times’ headline.

At least nine women in New York and seven more elsewhere had been diagnosed with serious infections, all traced to their having had cosmetic surgery in the Dominican Republic. The Times attributed the problem to “what has apparently become a phenomenon among New York City’s Latinas: cosmetic surgery conducted in the Dominican Republic after being arranged through beauty salons in Washington Heights and other city neighborhoods.”

The city’s health commissioner, Thomas Friedman, M.D., and other officials called the bilingual news conference in the city’s Washington Heights section for the express purpose of warning New Yorkers (and anyone else who would listen): Don’t even think about going out of the country to have plastic surgery — especially to the Dominican Republic.

“It is so important to get the message that something that is cheap can be very costly,” said New York City Councilman Miguel Martinez. “It can cost you your life.”

Officials vowed to shut down what they said was a loosely coordinated network for recruiting patients, which they referred to as a “big business.” They called in the national Centers for Disease Control and Prevention to investigate.

Notably absent from the story, however, was any comment from doctors, surgeons, or officials in the Dominican Republic, though The Times quoted several women from the Washington Heights area, who shrugged off the warning. One woman said she had had a $3,000 tummy tuck done in Santo Domingo a few years earlier without a problem. She told The Times she knew of hundreds of women from Washington Heights who had cosmetic surgery procedures done in the Dominican Republic and that only a few had complications. In fact, she said she was planning to go back again for more cosmetic surgery the next month.

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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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