Beauty from Afar

In Beauty from Afar, I refer to Dr. Prof.  Ivo Pitanguy of Brazil as perhaps the father of both modern cosmetic surgery and of medical tourism.

Chapter 3 Page 2 | The Pioneers

I had originally hoped the Dr. Pitanguy would write the foreword for my book, but that wasn’t going to happen without my taking a trip to Brazil that I wasn’t able to take on my budget at the time. However, his office, in the person of Pitanguy’s then-assistant, Henrique N. Radwanski, M.D., was generous with time and information.

Chapter 3 Page 2 | The Pioneers

Brazil, in particular, gradually became known internationally for the expertise of its aesthetic and plastic surgeons, but it was not a fame that extended to the mass consumer markets of the more economically developed world. Prof. Dr. Ivo Pitanguy is not a household name outside of his home country, where he is revered. Dr. Pitanguy has performed or guided thousands of surgeries in a storied, five-decade career and has trained more than 500 plastic surgeons from more than 40 countries who practice internationally, making cosmetic surgery expertise and technique one of Brazil’s best-known exports.

Among his peers, Dr. Pitanguy is regarded as the father of modern cosmetic surgery. He also has become the father of modern medical tourism, for those he has trained are among the most sought after surgeons in the world. Yet his name and his work, outside Brazil and South America, are familiar primarily only to other plastic surgeons, Brazilians living abroad, and the families and friends of his patients — not to the millions of potential plastic surgery patients in the United States who are far more likely to know the names of surgeons on Dr. 90210 or The Swan.

In the United States, if one had to name a doctor who was famous in international medicine during the 1960s, perhaps the only household name was Christiaan Barnard, M.D., the South African who performed the world’s first heart transplant in 1967. Notably, Dr. Barnard trained in the United States, as did Dr. Pitanguy, before heading home to eventual renown.

I cite Dr. Pitanguy and Dr. Barnard as pioneers not so much for their unquestioned skill as surgeons but because they achieved the kind of international fame that, for most of the 20th century, was reserved for doctors and scientists only in the West (North America and Western Europe) and, to a lesser degree, the East (mostly the former Soviet Union). Patients in Eastern bloc countries frequently traveled to the then-USSR and its allied nations for advanced medical care. For all of the 20th century, and even into the beginning of the 21st century, the vast majority of medical tourists were not jetting to South America or Africa, let alone the Far or Middle East. They were coming to the world’s great doctors and hospitals in the United States and in Europe.

From the perspective of the United States, in particular, this state of affairs served, and still serves, to reinforce the generally held belief that the United States has the finest medical care in the world. In the last 50 years, only Dr. Barnard’s achievement challenged this notion in the popular imagination. People were oddly comforted when Drs.  and Michael DeBakey started transplanting hearts in Houston, Texas, almost in the same way they were when the United States finally answered the Soviet space challenge of Sputnik.

Meanwhile, Dr. Pitanguy just kept doing what he was doing. Patients spread the word. Brazil was and is the mecca of plastic and cosmetic surgery, challenged only recently by Southern California. The surgeons Dr. Pitanguy trained spread out through South and Central America and around the world. Over time, a second essential precondition for medical tourism to emerge as big business was met — medical talent spread out, belonging less exclusively to the developed world. In economically emerging nations, improving health care was a priority — which meant building more modern medical facilities.

The quality of care in the less-developed world rose steadily, at least in metropolitan areas, but prices for medical services remained low, relative to the United States and Europe.

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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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Dr. John Corey, an aesthetic plastic surgeon in Scottsdale, Arizona, was kind enough to write the foreword for Beauty from Afar. I found him on the web long before I asked him if he would do that. There are not many cosmetic surgeons in the United States who are openly admiring of the work and advances made in other countries.

Specifically, John has trained at one of the most renowned cosmetic surgery facilities in Brazil He talks about how that has influenced his work in today’s segment:

Chapter 2 Page 7 | The Best of Both Worlds

I’m grateful to have had the benefit of John’s point of view and experience.

Chapter 2 Page 7 | The Best of Both Worlds

John J. Corey, M.D., a prominent plastic surgeon in Scottsdale, Arizona, is an ASPS member. However, he also advertises a Brazilian influence on his practice and his technique; Dr. Corey traveled to Brazil in 1993 and studied under the aforementioned Ivo Pitanguy, M.D.

“Brazilian surgeons seem to have a different “eye” for aesthetic surgery … a different way of analyzing beauty and the human form. We Americans have a tendency to be very technical. We want to know exactly how much to contour and how much to measure. Brazilians seem to approach procedures more artistically. They don’t rely on applying the same measurement to every woman. They really believe in sculpting the form and creating the curves and lines of the feminine shape.”

Dr. Corey doesn’t deny the obvious implication of his own words — that many Brazilian surgeons are incredibly good and that U.S. surgeons can and do learn a lot from them. And, like many other surgeons in the United States and abroad, he has used the Internet in building and extending his own practice. He has patients from out of state and out of the country. He also knows that not all patients can afford his prices, and that excellent surgeons, board-certified in Brazil and other countries, charge far less than he does in Scottsdale.

“The ASPS is going to come down on the side of caution and safety,” Dr. Corey said. “And I don’t think anyone can fault them for doing that; it is what doctors do. But at the same time, of course, there are well-qualified surgeons around the world. We interact with each other; we learn from each other. And economic conditions, and the cost of doing business, are different in other countries.”

Dr. Corey looks at medical tourism from a pragmatic point of view. “I think we have to look at more ways to cooperate, more ways in which we can serve patients better,” he suggested. “Clearly, overseas surgeons who are able to charge less are meeting a need in the market, and the market is evolving. There are ways in which doctors in the United States can be part of that, and in which patients will benefit.”

The ASPS, he points out, does list on its Web site “corresponding members” from overseas; there are not that many surgeons who have chosen to affiliate, however, and the ASPS notes that it can not vouch for their credentials.

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One of the great things about being a writer is that it gives one lots of opportunities to talk to interesting people one would otherwise never have met. For me, over the past 25 or so years, this has meant chatting with people ranging from accused murderers to U.S. Senators, the infamous and the celebrated.

For Beauty from Afar, I got to talk to doctors and surgeons. Lots of them. And they are a fascinating bunch. In today’s segment:

Chapter 2 Page 6 | Point, Counterpoint

… I compared and contrasted statements from two doctors, one from Texas and the other from Brazil, both renowned plastic and cosmetic surgeons.

I remember thinking that Dr. Rod Rohrich of Texas probably wanted to hang up on me while we were chatting on the phone and that I wouldn’t really have blamed him if he did. I was clearly writing something that was going to be at least somewhat at odds with his public pronouncements about going overseas for plastic surgery. I remain grateful that he took time to talk.

The Brazilian surgeon, Dr. Luiz Toledo, is now apparently working in Dubai! Links for both surgeons are provided in the segment.

The web site and staff of the International Society of Aesthetic and Plastic Surgeons (ISAPS) were both very helpful in my research. Sometime after Beauty from Afar came out, ISAPS published its own briefing paper on medical tourism which was rather less negative than the one put forth by the American Society of Plastic Surgeons.