Beauty from Afar

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.

The American Society of  Plastic Surgeons (ASPS) released in April 2005 what amounted to an acknowledgment that medical tourism exists, in the form of a briefing paper that got some media attention. This was when I was in the middle of researching Beauty from Afar and was pure gold, as far as I was concerned. In the end, I quoted and commented on the entire document — which makes today’s “page” pretty long. But I thought it best to keep all the material together.

Chapter 2 Page 5 | American Doctors Speak Out

By that time, I’d spoken with enough doctors and surgeons with varying opinions on the subject of medical tourism that I was pretty sure I had a more complete and nuanced view of the subject than the ASPS could possibly put out, given that they had to present a united view … and given their constituency. I felt qualified to comment despite my lack of medical credentials.

To the credit of the ASPS, they have updated their information and resources on medical tourism over the past few years. A new link for them is in the “author’s note” for the page … and also here.

(Author’s Note: The ASPS briefing paper referenced below has been revised and augmented with audio and video since 2005. Please visit this page at plasticsurgery.org for current information. However the overall advice remains true to the original briefing paper. If I were preparing a new edition of Beauty from Afar, this section would be rewritten … but would say many of the same things.)

Chapter 2 Page 5 | American Doctors Speak Out

What are the real risks against which to weigh the considerable cost savings? In April of 2005, the American Society of Plastic Surgeons (ASPS) issued a briefing paper that overwhelmingly cautioned against traveling abroad for surgery, though not in the stark terms used regarding going to the Dominican Republic. If one read nothing else, one would conclude that traveling overseas for plastic surgery is a poor idea. In the broadest context, however,the ASPS statement is full of sound advice for anyone considering cosmetic surgery. I offer the entire briefing paper, interspersed with commentary and context.

Cosmetic surgery tourism is a price-driven phenomenon that has experienced increased growth over the past decade. Numerous companies offering all-inclusive vacation packages that include cosmetic surgery are popping up all over the world and can be easily located via the Internet. The offers generally include private hospital services and tout “highly trained” and “credentialed” medical staff. Since elective cosmetic surgery procedures are not covered by insurance, price is the major selling point of cosmetic surgery tourism, with entire vacation/surgical packages costing less than individual procedures in the United States.

This is entirely true. Clearly, however, the ASPS disapproves of cosmetic surgery being a “price-driven phenomenon,” even as its member surgeons continue to work on devising lower-cost, less-invasive techniques and procedures and to compete with each other. U.S. cosmetic surgeons, however, in almost all circumstances, are unable to compete on price with their counterparts in the nip-and-tuck nations of Central and South America and Asia.

Although there are many skilled and qualified physicians practicing all over (the) world, the ASPS cautions that it may be difficult to assess the training and credentials of surgeons outside of the United States. Patients may take unnecessary risks, when choosing cosmetic surgery vacations, by unknowingly selecting unqualified physicians and having procedures performed in non-accredited surgical facilities. The ASPS urges patients to consider the potential complications, unsatisfactory results, and risks to general health that may occur.

Yes, it can be difficult to assess the training and credentials of surgeons outside the United States. Surgeons and facilities overseas that are marketing to prospective patients in the United States, however, have made it considerably easier. Overseas surgeons offer their credentials online, and ways of verifying them are available via Internet and telephone. Prospective patients can consult directly with surgeons and staff from other countries online; references can be provided and evaluated; consultations can be conducted by phone, e-mail, Internet chat, and even via Internet video. Indeed, many ASPS members are building Internet practices in exactly this way to draw patients from around the country and from abroad.

Plastic-surgery professional organizations, no doubt, would agree whole-heartedly that the ASPS certainly can not be faulted for urging patients to consider all possible risks and to be aware of selecting unqualified physicians who operate in substandard facilities. To that I would even add a further cautionary note: People who are considering the option of going overseas for cosmetic surgery, or any other kind of health care, should keep solidly in their minds that they must be ready and willing to walk away from the decision at any point: If they come to believe they have been misled about the surgeon’s expertise, the quality of the medical facility, the procedures involved, the price, or other terms, the right decision in the end may be to walk away. A patient who has done sufficient research is very unlikely to end up in such a position, but one must be mentally prepared to not go through with surgery if one develops serious doubts — even if it means cutting your losses on the expense of traveling there.

Vacation-related activities may compromise patients’ health. Cosmetic surgery trips are marketed as vacations. Although enticing, vacation activities should be avoided after surgery. To properly heal and to reduce the possibility of complications, patients should not sunbathe, drink alcohol, swim/snorkel, water ski/jet ski, parasail, take extensive tours (walking or bus), or exercise after surgery. Yes, some firms are marketing cosmetic surgery as vacation trips, and it is also true that some patients who go abroad allow for some vacation time by arriving early or extending their stays past the period of enforced recovery. Patients can certainly arrange to recover in comfortable, even luxurious, surroundings. But your surgeon abroad is going to tell you the same thing as well. Further, patients should budget extra time at the end of their trips, bearing in mind that complications and infections are possible and that you can not absolutely count on being physically ready to go home on a pre-arranged schedule.

Cosmetic surgery is real surgery. At the highest level of care, every surgery, including cosmetic surgery, has some risks. These risks may increase when procedures are performed during cosmetic surgery vacations. Infections are the most common complication seen in patients that go abroad for cosmetic surgery. Other complications include unsightly scars, hematomas, and unsatisfactory results. Travel combined with surgery significantly increases risk of complications. Individually, long flights or surgery can increase the potential risk of developing pulmonary embolism and blood clots.

Traveling combined with surgery further increases the risk of developing these potentially fatal complications, in addition to swelling and infection. Before flying, the ASPS suggests waiting five to seven days after body procedures such as liposuction and breast augmentation and seven to 10 days after cosmetic procedures of the face including facelifts, eyelid surgery, nose jobs, and laser treatments.

All good points, but it is also the same advice you would get from a qualified surgeon in any other country. Patients shouldn’t ignore this advice. I don’t mean to place blame, but far too many cosmetic surgery horror stories can be traced, in part, to patients not following a doctor’s orders for the recovery period.

Travel can be stressful and exhausting, and attempting it too soon after surgery can impede recovery. Despite the ominous tone of this caution, individual surgeons I talked to agree with this sentiment: Follow your doctor’s orders if you want your best chance at a trouble-free recovery. Don’t travel until your doctor says it is safe to do so.

In addition, airlines make special provisions for patients who are traveling with disabilities, and that includes travelers who have had recent surgery. If you have a long trip with flight changes, for example, it may be prudent to call the airline in advance and arrange for wheelchair service.

Follow-up care and monitoring may be limited. Follow-up care and monitoring is an important part of any surgery. Cosmetic surgery vacation packages provide limited follow-up care, if any, once the patient returns to the United States. Patients who have traveled outside of the United States for cosmetic surgery and experienced a complication may find it hard to locate a qualified plastic surgeon to treat the problem or to provide revision surgeries. Local doctors may not know what surgical techniques the physician used in the initial operation, making treatment difficult or nearly impossible. Revision surgeries can be more complicated than the initial operation and patients rarely get the desired results.

In general, this is true and should be considered carefully, especially regarding follow-up care. Some patients are afraid to tell their family doctors what they are going to do, or have already done. It’s best to be as prepared as possible for complications. Many experienced patients recommend consulting with your family doctor before going overseas. Also, reputable overseas surgeons are available for consultation with you or with your doctor at home via e-mail and telephone. This is not a deal-breaker, but it is something to think about.

Bargain surgery can be costly. Patients can incur additional costs for revision surgeries and complications that may total more than the cost of the initial operation if originally performed in the United States.

Well, yes. That can happen. Bluntly, it can happen in the United States as well, and you’ll be out far more money in the end. Choosing a qualified and experienced surgeon is your best chance at minimizing the risk of bad surgery that can lead to additional rounds of expensive surgery. Good cosmetic surgeons overseas often charge far less than good cosmetic surgeons in the United States. The ASPS cannot really quite get around that fact.

You should ask your surgeon in advance what his or her policies are on revisions, should you be dissatisfied. Some will do revisions for free, in certain circumstances, or for a reduced charge. A cosmetic surgeon’s best advertisement is satisfied customers.

Surgeon and facility qualifications may not be verifiable. In order for cosmetic surgery to be performed safely, it requires the proper administration of anesthesia, sterile technique, modern instrumentation and equipment, as well as properly trained surgeons. Vacation destinations may not have formal medical accreditation boards to certify physicians or medical facilities. Many facilities are privately owned and operated, making it difficult to check the credentials of surgeons, anesthesiologists, and other medical personnel. There are no U.S. laws that protect patients or mandate the training and qualifications of physicians who perform plastic surgery outside of the United States. There may be no legal recourse if surgical negligence by the physician or institution occurs.

If the surgeon’s credentials and the quality and standards of the surgical facility can’t be reasonably verified and vouched for, you shouldn’t go. Simple.

As to legal remedies, should a patient be dissatisfied with surgery — or maimed or killed by it — it is true that it is easier and far more convenient to sue a U.S. doctor in the United States than it is to attempt to litigate outside our borders. However, suing a plastic surgeon in the United States is far from a slam-dunk, and reputable surgeons here and abroad are generally willing to extend themselves to produce a happy patient rather than a disgruntled one who will call a lawyer.

Devices and products used may not meet U.S. standards. Cosmetic surgery products or devices used in other countries may not have been tested, proven safe and effective, or been approved by the U.S. Food and Drug Administration (FDA). For example, an implant used in the United States must meet standards of safety and effectiveness, a process regulated by the FDA. Other countries may not have similar regulations.

Patients should, of course, check on what substances are injected and what devices are being inserted into their bodies. However, one of the reasons many American women have gone abroad for breast augmentation is the availability of silicone implants, banned by the FDA in 1992 but popular in other parts of the world. It is possible that silicone implants may again be widely available in the United States because the ASPS says silicone is safe and that the FDA should drop the ban, arguing that patients should have the option of choosing silicone. The ASPS says silicone implants are safe and the FDA, at this writing, seems inclined to allow wider testing. The ban could well be lifted at almost anytime.

(Author’s Note: The ban was lifted in November 2006, five months after Beauty from Afar was published.)

The ASPS briefing paper goes on to name Argentina, Brazil, Costa Rica, the Dominican Republic, Malaysia, Mexico, the Philippines, Poland, South Africa, and Thailand as cosmetic-surgery trip destinations, noting that these countries offer everything from “safari and surgery” to “tropical, scenic tour” vacation packages. It concludes with a useful checklist of questions to ask when choosing a cosmetic surgeon, clearly advocating the selection of an ASPS member. Point by point, however, the briefing paper offers advice no different than one would get from a qualified surgeon overseas — and, the ASPS, however briefly, acknowledges there are many of them.

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I have always attributed the phrase in the headline to Mark Twain, among my favorite authors … but I see by Wikipedia that it is of mixed or uncertain parentage. No matter. Please consider the link as a footnote to this post … my sixth footnote of the day. Earlier, I added what had been the five end notes to Chapter 1 of Beauty from Afar to the online pages where they belong, turning them into footnotes.

I see that I felt rightfully obligated to be fastidious about attributing statistics and numbers to their original source; and careful and fair readers should note that I chose sources that are known for doing good research and that I couch  prose that surrounds any  statistics rather carefully. There is almost nothing worse in journalism or argument than using bad statistics, or using good statistics badly, and it is done all the time.

To the extent that I am not guilty, I credit a professor of mine, Edward Tufte, whom I knew originally in the 1970s when he taught undergraduates at Yale. He has gone on to much bigger things.

Here, again, is the link to the last bit of Chapter 1:

Chapter 1 Page 9 | Medical Tourism: A Moving Target

We’ll begin Chapter 2 … oh, well. Before Monday, certainly.

There was a time when I thought that perhaps I ought to put myself forward as a reasonable candidate to be the caretaker and editor of Wikipedia’s entry for medical tourism.

Upon careful consideration, I realized that I would rather stick my hand in a bee’s nest. This is nothing against Wikipedia, which I think is a wonderful project; and I conclude Chapter 1 of Beauty from Afar with some direct quotes from Wikipedia. It was remarkable how the entry for “Medical Tourism” evolved in a short time:

Chapter 1 Page 9 | Medical Tourism: A Moving Target

… And the reasons which I am glad I did not become, or try to become, the Wikipedia editor of the page, are not yet apparent, in the above-linked passage from Beauty from Afar.

If you look at the current entry, you’ll see that it has evolved through a contentious few years. Many people have added and deleted and bitterly disputed sentences, paragraphs and sections of the entry, over time. It has been a bone over which dogs of the medical tourism industry fought. I make no apologies for the analogy. Medical tourism “experts” in every country with any claim to being a medical travel destination have vied to define the reality of medical travel. Bias was inevitable.

The entry is not so bad now as it was at a few stages in its evolution. For a partial discussion of the issue of bias, take a look at the Wikipedia “Talk” page on the Medical tourism definition/entry.

Bees sting.

Anyway — Chapter 1 of Beauty from Afar is now posted completely. It is in 9 online pages, rather than the 18 in the printed version of the book. I do have to add the end notes to the chapter but have decided to go back and insert them as footnotes to the appropriate pages in this online edition; so I’ll probably do that tomorrow, before commencing with Chapter 2.

Also, a technical note: I have made BeautyfromAfar.com a dofollow blog, which means that links on this blog have relevance to search engines. Many blogs use a “nofollow” default, meant to discourage comment spam. I don’t see the point, since I delete comment spam and blatant marketing attempts with extreme prejudice. If you have something to add to the discussion here, I want you to get credit for doing so, with a link from your name to your site, at least. (And if you don’t understand this paragraph, it probably doesn’t apply to you.)

Chapter 1 Page 9 | Medical Tourism: A Moving Target

Among the great advantages of the Internet as a publishing medium is that it can be updated quickly and efficiently, and among the loveliest examples of this is Wikipedia, the free online encyclopedia. “Medical Tourism” was born as an entry in Wikipedia in June 2004; the initial entry read, in its entirety:

“Medical tourism is the practice to visit countries with low prices and buy services in their private hospitals.”

By September 2005, the entry had expanded to:

“Medical tourism is a term that has risen from the rapid growth of an industry where people from all around the world are traveling to other countries to obtain medical, dental, and surgical care while at the same time touring, vacationing, and fully experiencing the attractions of the countries that they are visiting. A combination of many factors has lead to the recent increase in popularity of medical tourism: exorbitant costs of health care in industrialized nations, ease and affordability of international travel, favorable currency exchange rates in the global economy, rapidly improving technology and standards of care in many countries of the world, and most importantly the proven safety of health care in select foreign nations have all led to the rise of medical tourism. More and more people are traveling abroad as an affordable, enjoyable, and safe alternative to having medical, dental, and surgical procedures done in their home countries.

“Medical tourists are generally residents of the industrialized nations of the world and primarily come from the United States, Canada, Great Britain, Western Europe, Australia, and the Middle East. But more and more, people from many other countries of the world are seeking out places where they can both enjoy a vacation and obtain medical treatment at a reasonable price.

“Currently, medical tourists are traveling in large numbers to India, the East Indies, and South America — three places where the quality of health care is equal to anywhere else in the world and yet the cost is significantly lower. These regions also offer numerous options for touring, sightseeing, shopping, exploring, and even lounging on sundrenched beaches. Although India, the East Indies, and South America are currently the most popular choices for medical tourists, the industry is growing so rapidly that more and more countries and medical centers around the world are beginning to tailor services aimed specifically at medical tourists, and the expectation is that the options for where medical tourists can choose to travel will continue to increase at a rapid pace.

“A myriad of options exist for medical tourists,  from purely elective procedures such as rhinoplasty, liposuction, breast augmentation, orthodontics, and Lasik, to more serious and life-saving procedures such as joint replacements, bone marrow transplants, and cardiac bypass surgery. Medical tourists can now obtain essentially any type of medical or surgical procedure abroad in a safe and effective manner for a fraction of the cost that they would face in their home countries. The cost savings are enormous. For example, for the same price as a week-long vacation for two in Hawaii that includes airfare and boarding and lodging, a couple can travel to the natural and lush beauty of Kerala on India’s southeast coast to include airfare, boarding and lodging, personal tour guide/concierge, and Lasik corrective surgery for two.

“The average cost of private heart surgery in the United States is $50,000. That same operation with comparable rates of success and complications costs only $10,000 in the finest and most state-of-theart hospital in Bombay. A bone marrow transplant that costs $250,000 in the U.S. costs only $25,000 in India. Large price disparities such as these exist across the board for numerous medical and surgical procedures. And because of favorable currency exchange rates for medical tourists, the costs associated with accommodations, food, shopping, and sight-seeing are similarly very favorable.”

Phenomena come and phenomena go, of course. But the evidence is that medical tourism will be with us for a while. It has just begun.

(Current Wikipedia Entry for “Medical Tourism)

End, Chapter 1 Beauty from Afar

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