Beauty from Afar

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 1 |  A Brief and Selective History of Medical Tourism

(A (necessarily) brief history of traveling for health care)

My dear Athos,

I wish, as your health absolutely requires it, that you should rest for a fortnight. Go, then, and take the waters of Forges, or any that may be more agreeable to you, and recuperate yourself as quickly as possible.

Yours affectionate,
de Treville

From The Three Musketeers
Alexandre Dumas

***

The history of cosmetic surgery, and of traveling extended distances for medical care or health reasons, goes back to the beginning of recorded time. Reconstructive plastic surgery procedures were performed in India at least as far back as 600 B.C. (1)

Literature and history are replete with stories of people who have traveled for health reasons; the healing and recuperative powers of bathing in the hot mineral springs around the world is documented in both fact and in fiction. School children are taught that the Spanish explorer Ponce de Leon allegedly went in search of the Fountain of Youth and found Florida and death by an Indian arrow instead. I say “allegedly” because a number of scholars dismiss the Fountain of Youth part of the story as myth. In more recent history, Franklin D. Roosevelt received therapeutic baths and muscle treatments for his debilitating pain from polio in Warm Springs, Georgia during his administration from 1933-1945, making the place sort of a southern White House for months at a time.

You could say that President Roosevelt was a pioneer of modern health tourism, the precursor of medical tourism, though the two are distinct, historically and even today. Health tourism is the business of spas selling weekend or week-long indulgences of luxurious massages, exotic baths, healthy foods, beauty makeovers, and soothing or exhilarating scenery for an even more exhilarating price. Some even have a spiritual component. The actual medicinal value of much of this has long been debated, though many medical professionals vouch for their therapeutic benefits.

Medical tourism, on the other hand, is entirely recent and has become the more narrowly applied term for traveling abroad for the services of a doctor or surgeon. Recuperating in a spa or vacation-like setting is an option, and an attractive embellishment for many. While, no doubt, there are scholars who could step forward with examples from history of people who traveled great distances for the services of a particular doctor or a particular treatment or surgery, they would also acknowledge that medical tourism is mostly a modern phenomenon. It tracks very closely with the 20th century refinement of cosmetic surgery as a medical specialty spawned from necessity during World War I when reconstructive techniques were developed to treat those maimed in combat.

By the 1950s, the groundwork for what was to become modern cosmetic surgery had been laid. Though far from common, surgery for purely aesthetic reasons had become less peculiar. Initially there was little competition. Through the 1950s and 1960s cosmetic surgery was the province of the United States and Europe; the clients, whatever nationality, were mostly wealthy. Quick, affordable international air travel was the first precondition for medical tourism to emerge and international patients started to head for the great hospitals of the United States and Europe, as they still do today. The main difference today is that the international competition to provide medical services has become fierce.

In addition to the patients, however, an ever-increasing number of medical students, doctors, and surgeons from around the world converged on the United States and Europe seeking medical training. As time passed, more information was exchanged and spread; more technology was were shared. Some of the medical students stayed in the United States as part of the infamous “brain drain” that was attracting the best and the brightest from around the world, to the detriment of efforts to modernize and improve economic conditions abroad. But some went home to build medical practices in their own countries and to found new institutes, hospitals, and centers of learning. Among the skills they took with them were cosmetic surgery techniques.

In time, inevitably, other destinations for patients besides the United States and Europe arose.

(1) Rana RE, Arora BS. History of plastic surgery in India. J Postgrad Med 2002; 48:76-8

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Prices for cosmetic surgery vary widely based on a number of factors, as I point out in the concluding segment of Beauty from Afar‘s Chapter 2:

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

Being a surgeon, particularly being a surgeon for uninsured, elective procedures, is a business, wherever one is located.  And the global recession has had an impact on the business of cosmetic surgery. This report is from January 2009, but I rather doubt that cosmetic surgery is less recession-proof than the rest of the economy:

Cosmetic surgeons suffer recession, says new survey

Well-established practices are weathering the storm. Not-so-well established practices are not, and some are not surviving.

Anywhere in between? Whether in the U.S. or abroad, cosmetic surgeons are getting more creative about marketing to patients and that means, often, that patients have some bargaining power when it comes to price.

No sane person chooses a surgeon solely on the basis of price. But discounts can be attractive.

That finishes up Chapter 2, hooray! I have no idea if anyone is following along day by day, but the visitor count has been rising steadily. On to Chapter 3 … which is a brief history of medical tourism.

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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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 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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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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So the introduction to Beauty from Afar is now completely online. The concluding segment is Competition for the United States.

The intro seems short to me, maybe because I vaguely remember agonizing over writing it a few short years ago. There are only five segments; in the physical book, the introduction is only nine pages. Online, it is just five.

But it says what it needed to say. The difficulty in writing it, originally, was in deciding what to leave out; what to save for later. That was where having written a book proposal came in really handy. I trusted my outline.

Beauty from Afar was primarily aimed at readers in the United States, though I tried to make it clear that consumers of hospital care, cosmetic surgery and dental services in other countries could also learn a thing or two and might want to consider traveling for medical procedures. But by reasons of history, geography and national psychology, it seems that it is Americans who had the biggest leap of faith to make, to trust doctors in countries other than their own.

I touch on this in the brief “It’s so … Foreign” segment of the Introduction.

One more intro section to go and I can move on to Chapter 1 …