Cosmetic surgery, like all surgeries, has the risk of after surgery complications. But cosmetic surgery us unique is that it has two distinct types of complications…medical and cosmetic. Medical complications are events like infection or DVT. Cosmetic complications are an undesired or unexpected appearance like an implant being too big or an out contour that is irregular or asymmetric What the exact type and risks of complications are varies for each type of cosmetic surgery.
CosmetAssure is an insurance company that offers patients some financial protection against medical complications from approximately twenty of the most common cosmetic surgery procedures. Since this company provides such coverage they are in a position to have a unique insight into the rate of these complications. They have accumulated a large database from which the data has been statistically analyzed over a five year period. The data has shown the following top ten statistics.
The major or medical complication rates for cosmetic surgery is around 2%. Liposucton, which is often perceived by the public has having a relatively high risk, shows a major complication rate of less than 1%. That risk does increase considerably up to 4% when combined with a tummy tuck and at 12% when combined with multiple other body contouring procedures.
Medical complications rates in tummy tuck surgery were 3% and increased as high as 10% when combined with other body contouring procedures such as liposuction. Combining liposuction with a tummy tuck doubles the risk of a DVT (deep vein thrombosis) from 0.5% to 1%.
In breast surgery, placing breast implants had complication rates of 1.5% which was similar to that of a breast lift. However, when both implants and a lift are done are done at the same time, the complication rates increases to 2%.
While major complications in facelifts are rare, patients that were overweight (BMI greater than 25) have a higher rate of infection. (3%). Men are more prone to hematomas after a facelift than women at a rare of 4%.
There was no statistical difference between older vs. younger patients in complication rates from cosmetic surgery, supporting what has been believed for a long time. However, when looked at on the other end of the age spectrum, cosmetic surgery in teenagers (0.5%) was much lower than in in adults. (1.5%) This undoubtably is due to the more limited types of cosmetic procedure performed in young patients.
Sex did not make a difference in major complication rates with men and women being fairly equal at just over 2%. However, regardless of gender, being overweight increases the complication rates for both men and women.
The popularity of all forms of cosmetic surgery is growing and it spans all ages from teenagers to senior citizens for a wide variety of procedures. Age knows no limits when it comes to self-improvement and the desire to look as good as physically possible. While younger patients do inquire as to the safety of certain cosmetic surgery procedures, that very question becomes much more relevant in older patients who may more ailments and medical problems. Even when very healthy older patients naturally ask if their age places them at greater risk for complications.
In the September 2015 issue of the Aesthetic Surgery Journal an article on this topic appeared entitled ‘Safety of Cosmetic Procedures in Elderly and Octogenarian Patients’. To evaluate the incidence of complications from elective aesthetic surgery in patients over age 65 (so called ‘elderly’), the authors looked at a data base of over 180,000 patients from the company CosmetAssure’s data base. Postoperative complications in elderly and younger patient groups were compared with a separate. analysis of postoperative complications in patients over 80 years old. From this database just over 6,700 patients over 65 years old were identified with an average age of 69 years old and with a higher number of men with higher body mass indexs.
They found that the postoperative complication rates was not higher than that of younger patients.When looking at the type of cosmetic procedure, only a tummy tuck had greater complication rates in older patients.The most common postoperative complications in older patients were infection and bleeding. (hematoma) Also the octogenarian patients had a complication rate of around 2% which was not different than that of any other age group.
As the U.S. population grows an older number of cosmetic surgery patients have come forth more than ever before. The first question that both plastic surgeon and patient alike ask at older ages is…is having this operation safe? Is the patient at increased risk because the patient is older? It is the plastic surgeon’s perception and experience that this is not so. This study supports that belief using data from a company that knows complications from having to insure against them and pay for them if they should occur.
Since almost all of cosmetic surgery is an out-of-pocket expense, the consideration of cost is extremely important. Many patients save up for some time for their surgery, borrow the money from family or banks, or most commonly, finance it through a variety of means. For many patients they have just enough or it is just within their budget to afford the surgery. But from a financial aspect, this is a bit of a dangerous approach. It does not account for the possibility of the need for revisional surgery. While no patient ever really thinks that their result will not be perfect or everything they thought it would be, the reality is a significant number of patients (an overall average risk is 10% to 15%, may be higher or lower depending on the procedure) may either need or want some form of a ‘touch-up’. Most of the time this is for aesthetic improvement and not any major problems, but the ‘problem’ is just as real for the patient. While patients usually willingly accept a revisional surgery, the sticking point is always the cost of doing it. Patient usually feel that they should not have to pay anything for a revisional procedure. While this is an understandable feeling, it does not take into account the economics of surgery and many costs that the surgeon can not control. Usually what the costs of a revisional surgery may be are spelled out beforehand but, if not, you need to find out what potential costs may be incurred. Thus number should then be put into the overall cost of the cosmetic surgery and used to determine if you really can afford it.
‘The Affordability of Any Cosmetic Surgery Should Take Into Account The Potential Added Cost Of A Revision’
The use of dietary supplements is the norm today rather the exception. Between the use of vitamins and herbal supplements, it is estimated that nearly half of the U.S. population is partaking of these alternative or complementary oral aids. This does not take into account whatever pharmaceutical medications that they may also be ingesting. Put together it is not uncommon today to have a cosmetic surgery patient who is taking three, four or five oral medicines even though they have no major medical problems.
Without asking specifically on an intake form in a doctor’s office, some patients do not voluntarily report their supplement use. They may do so because they do not feel they are relevant to having surgery or do not want to admit that they take them. How prevalent is this patient behavior?
In the July 2013 issue of the journal Plastic and Reconstructive Surgery, an article was published on this topic entitled ‘The Incidence of Vitamin, Mineral, Herbal and Supplement Use in Facial Cosmetic Patients’. A retrospective review was done on 200 facial cosmetic surgery patients from a single plastic surgeon’s practice based herbal and nonherbal supplement use. They found that supplement use was nearly 50% amongst the studied patients of which 25% used only vitamins and minerals. In those using herbal supplements, they averaged using nearly three per patient. Herbal supplements were more likely to be used in women over the age of 50 while vitamin and mineral supplements were used by younger patients and men were more prone to take them.
Knowing whether a patient undergoing plastic surgery is using herbal medications is important as some of these supplements can increase intraoperative and after surgery risks. Herbal medications, such as echinacea, ephedra, ginkgo, ginger, St. John’s wort and valerian, have been identified as having adverse reactions such as immunosuppression, cardiovascular effects of hypertension and arrhythmias, hepatotoxicity, increased bleeding and interference or prolongation with various anesthetic agents.
It should not be any surprise that many cosmetic surgery patients have a higher incidence of oral supplement use given their attention to face and body image improvements. Patients should be aware that they need to stop these supplement uses at least 2 and preferably three weeks before their surgery. This is the known time that any potential adverse effects of these supplements should pass as their residues and breakdown byproducts are excreted from the body. Such recommendations are completely in line with that of the American Society of Anesthesiologists. If in doubt as to whether any alternative medication use may interfere with your upcoming plastic surgery, stop it as a few weeks of not being on them will have no adverse health effects.
The number of cosmetic procedures continues to increase every year. The latest statistics from the American Society of Plastic Surgeons (ASPS) for 2012 show that over 14 million cosmetic procedures were performed. While less than one-third of them were major surgical procedures, every cosmetic procedure no matter how minor has some level of risk. While the enthusiasm of undergoing a cosmetic change puts blinders on the potential downsides, risks and complications these procedures still do exist.
Major medical complications from plastic surgery are, fortunately, very uncommon. But if a complication developed that required a visit to the emergency room or even hospitalization, would your medical insurance cover the cost? That is a good question and the answer is far from certain. Some medical insurances specifically exclude any coverage for problems that arise from cosmetic surgery procedures. Even if covered, the often high deductibles that may people may carry today could expose one to thousands of dollars of unexpected expenses.
CosmetAssure is a company that offers an affordable option for cosmetic surgery patients to avoid the financial risks of unexpected after surgery complications. Endorsed by ASPS, it is risk insurance that is only offered through board-eligible and board-certified plastic surgeons to their patients. Patients may elect to purchase this option (enroll) prior to their elective cosmetic procedure. The following twenty-one major procedures are covered under the policy:
Abdominoplasty (tummy tuck)
Arm Contouring (brachioplasty)
Breast Augmentation Revision
Chin Augmentation/Chin Reduction/Jaw Implants
Eyelid Surgery (Blepharoplasty)
One of the major restrictions of the policy is that it covers complications which occur only within a 30 day period from the onset of the anesthesia for the procedure(s). This is usually when most medical complications will occur anyway. It covers medically necessary expenses from an unscheduled admission to a hospital, emergency room or surgery center. Such complications may include such problems as bleeding/hematoma, infection, wound dehiscence/complications and DVT. (deep vein thrombosis) It does not cover aesthetic concerns or dissatisfaction from the procedure(s).
Somewhat similar to buying travel or trip insurance, this is low cost protection against the unlikely event of major medical problems from cosmetic surgery. Available now in all 50 states (and Puerto Rico), it is an option that prospective cosmetic surgery patients should be aware.
While over 14 million plastic surgery procedures were performed in 2012, the types of procedures differed considerably across the various age groups. The age group of 35 to 50 year-olds makes up the highest percentage (43%) with efforts being made to slow down the effects of aging which are now unavoidable to overlook. This is why this age group accounts for almost 50% of Botox and injectable filler use. Concomitantly, the use of laser, chemical peels and light therapies are also prevalent in an effort for skin improvement and wrinkle reduction. Reversing the effects of childbearing are seen in the high number of breast augmentations, tummy tucks and liposuction in this age group as well. The age group 51 to 64 year olds are the next highest users at 28% of the cosmetic pie. As 60 is the new 50, facial surgical procedures dominate with nearly two-thirds of all eyelid lifts, browlifts and facelifts occurring in this group. The 19 to 34 year-old age group accounted for 20% of procedures done with breast augmentation, liposuction and rhinoplasty being common surgeries and laser hair removal and microdermabrasion being the most commonly done non-surgical procedures. At the opposite ends of the age groups, the 65 and older group (9%) and under the age of 19 (1%) made up the rmaining 10% of the procedures performed.
Stem cells are the rage in medicine and their potential application for cosmetic changes is no exception. Since fat has become discovered as a resplendid source of stem cells, it has become relatively easy to acquire one’s stem cells from liposuction harvests and grow them in great numbers. As a result, numerous private laboratories have emerged offering stem cell growth and storage. This has led to numerous doctors across the country offering so-called stem cell cosmetic procedures and injections.
The appeal of stem cells therapies to potentially improve aging, wrinkles and sagging tissues is understandably irresistable. But one of the stark realities of stem cells is that no one knows what they will actually do if implanted. While the understanding of the basic biology of stem cells is well known, how they interact with other cells and materials after being implanted is far from an exact science. There are presumed to have remarkable regenerative properties, but there is not one single scientific paper that has ever actually shown that to be true in human application. Quite frankly, stems cell for cosmetic applications in humans is really an experiment even if it is the patient’s own grown cells that being used.
This human experimentation of stem cells in cosmetic surgery is illustrated in a recent report that appeared in Scientific American. A California woman complained of a swollen eyelid, an inability to open it well and hearing a strange sound when she did months after having received a new cosmetic procedure months earlier. The procedure was a ‘stem cell facelift’ where stem cells obtained from her fat by liposuction and then isolated were injected in combination with an injectable filler around her eyes. In subsequent surgery on her eyelids, a different surgeon than the injector removed bone fragments around the eye which were the source of her swelling and eyelid motion restriction. The sounds the woman heard appeared to have been caused by bone fragments rubbing against bone fragments.
While the injectable filler used was not identified in this report it undoubtably was Radiesse, a particulated filler that contains calcium hydroxyapatite particles as part of its composition. The stem cell treatment appears to have been a concoction of Radiesse and stem cells with the theory presumably being that it would improve the longevity of the filler’s effects. What was not predicted was that some of the hydroxyapatite particles served as a nidus for stem cell conversion into bone. In hind sight, this potential reaction seems obvious. But the euphoria of using stem cells and the lack of any previous studies using this combination led to this one patient’s unprecedented iatrogenic affliction.
It is important for patients to understand that the FDA has not approved any cosmetic procedures which use stem cells…or at least so claims. The more common and widely popular use of fat injections undoubably contains stem cells but their incorporation into the injectable treatment is inadvertent and the stem cells are not altered. Extracting stem cells and isolating and manipulating them for re-injection for human cosmetic alteration is now unapproved and requires a controlled FDA-regulated study in which to do it.
Whether stem cells are the fountain of youth for humans, or at least offers some spot areas of physical improvement, will now await years of further study.
Almost every week there are reports from somewhere in the U.S. of ‘botched’ cosmetic surgery. This does not refer to the patient who has a slightly uneven facelift, prolonged forehead numbness after a browlift, liposuction irregularities, concerns about breast lift scarring, or a dog ears after a tummy tuck. Not that these are completely trivial to the patient who has them but these are within the scope of expected outcomes from the procedure and are largely aesthetic in nature. ‘Botched’ cosmetic surgery pertains to disasters resulting in severe medical complications including death.
Some of the most recent botched surgery examples include include full-thickness scalp loss from a hair transplantation (loss of the scalp on the back of the head), hand paralysis due to severed nerves from a transaxillary breast augmentation, liver lacerations from liposuction and death from caulking compounds injected into the buttocks- just to name a few. While the internet makes just about any story newsworthy and exposed, these are well beyond being a sensationalized story. Such tragedies would have been news even back in the days when there were only three TV stations.
At the heart of these tragic events were the qualifications of the physician, or more specifically, the lack thereof. The definition of incompetence during a truly botched surgery is either having little anatomic and technical knowledge of how to perform the surgery (training) or technically knowing how to complete the procedure but performing it in a completely reckless manner (temporary or prolonged incompetence). The tragedy of these botched cosmetic surgeries is that almost all of them were done by doctors who had no formal training in plastic surgery – or who received any surgical training- or were not even licensed physicians at all. Lack of adequate, specialty-specific training is the major crux of most dire cosmetic surgery complications.
The compelling questions are 1) how can this happen in the U.S, the most regulated medical industry in the world, and 2) what can I do to avoid being the next victim? Adequate and specific training of the physician is the first and most important requirement for the procedure. There are some controversies regarding what constitutes ‘adequate’ training, and there are conflicting opinions as to the differences. For example, between a plastic and a cosmetic surgeon; in title alone they may or may not be the same – the training is reflected in whether the surgeon has Board Certification. But a little investigation and some common sense will go a long way toward protecting yourself from bad outcomes. Few doctors- unless they are incredibly bold- would call themselves board-certified plastic surgeons without the qualifications to back up this claim. By the way, the validity of that claim can be quickly verifeid (contact the American Society of Plastic Surgeons – ASPS.org) and false claims of this level of certification are typically dealt with very seriously.
The claim of being a ‘cosmetic surgeon’ is the confusing one because it is an unregulated concept. It is a general marketing term that may imply an extension of the doctor’s basic training into cosmetic work on similar anatomic regions (reasonable training), some training in certain procedures from a twenty-five year-old society (may be reasonable) or just a doctor who chooses to do some cosmetic ‘work’ without any real training at all (unreasonable). Either way, their base training is not the regulated training of plastic surgery but in some other medical field. Arguments are made that some of this work is equivalent to those doctors with more formal training. That is a debate for another day. The bottom line is… don’t count on doctors to help you evaluate their qualifications.
Ultimately it is the patient’s responsibility to investigate and use common sense. Should a gynecologist be doing hair transplants or breast augmentations? Conversely, would you choose a plastic surgeon to deliver your baby simply because he or she is a physician? Should an internist or emergency room doctor being doing your liposuction? Should an ear nose and throat doctor being doing your tummy tuck? Should an eye doctor perform your rhinoplasty? These examples occur daily in most large cities simply because many patients are unaware of the underlying difference in training. Choosing to have surgery with a physician who has not had the most advanced specialty training does not mean you’ll have a bad aesthetic result, but it does greatly increase the risk that you’ll have a seriously life-changing complication. When things go wrong during surgeries as they sometimes do, a lack of knowledge may not only be what creates a problem but will make it extremely difficult or impossible to reverse what has happened.
Beyond a doctor’s training, a red flag or warning sign is price. Low prices for cosmetic procedures are understandably attractive to prospective patients but all too often are low for a good reason. This does not mean that high prices guarantee great results or safety either. But low prices for procedures, often incredulously low by industry standards, exist to ensnare the most undiscerning of patients. Bear in mind that medical care – whether for an elective cosmetic procedure or an angioplasty- should never be sought at a ‘bargain’ price. An undiscerning patient who will overlook a doctor’s training to have a chance to undergo the cosmetic changes they have dreamed about. But in some cases that are becoming all too frequent, that dream turns into a nightmare.
There are numerous trends in plastic surgery that are on the rise but one in particular is extremely disturbing. The increasing number of injuries and horrific outcomes from so-called ‘illegal plastic surgery’. This term is a bit offensive to real board-certified plastic surgeons because they are not at all behind these illegal activities. Rather the illegal refers to people masquerading as doctors performing cosmetic procedures…with no medical license or any formal plastic surgery training.
The rise of underground and barely legal cosmetic procedures was highlighted this past week with a Mississippi woman charged with murder after killing a woman from injecting a large quantity of a silicone substance into her buttocks. This resulted in blood clots to her lungs and death by pulmonary embolism. How a person woke up in the morning, decided to her buttocks injected in a non-medical location by someone with no medical training and ended up dead baffles the imagination of rationale thought.
Over the past several years there are more and more stories, often not fatal but no less incredulous, of non-physicians doing injections of some sort in some of the most bizarre locations. And this is not just a trend in the U.S., it is being seen all over the world. The actual number of medical problems caused by illegal procedures is not known and certainly underreported because it lies well outside of organized medicine and state and federal laws.
What is the driving force behind such underground and illegal cosmetic procedures? Economics is the obvious answer as prospective patients look for bargains, an easy and cheap way to get that desired look. But economics alone is the tip of the iceberg. Every scam or con also requires a willing subject and in this case it is a very uninformed person. One of the common perceptions about cosmetic surgery, because it is not fixing a painful or dysfunctional medical condition, is that it is ‘no big deal’ and not real surgery. This perception is magnified when it comes to today’s commonplace injectable aesthetic treatments.
Such illegal cosmetic procedures commonly include buttock injections with a variety of substances to many of the standard injectable neurotoxins and fillers. Liposuction is one of surgical procedures that has also reached illegal levels with inexpensive purchases and only a standard wall outlet to turn them on. Not even a medical license is required to purchase most of the basic equipment.
As injectable treatments have migrated from traditional medical offices to such places as hair salons and spas, their perception of being a medical procedure has diminished. For many, Botox and fillers is just a commodity now and getting it is no more significant than using the drive through at Starbucks. For the most uneducated and eager, it is easy to see how buttock injections performed in a home or hotel room doesn’t seem that ‘risky’…if the price is right.
The basic principles of safe and effective cosmetic procedures is the same as it has always been. First, the procedure should be performed by a physician with an active medical license that is board-certified with very specific training in plastic or cosmetic surgery. This would be evident by such certificates on the walls or on their websites. It would also be reassuring that the physician has privileges at a local hospital, which also signifies credentialing of formal medical training. Second, the location in which the procedure is being performed should be a medical environment that is both clean and uses sterile supplies. Third, the fee should be appropriate for the procedure. Very inexpensive fees for services could well mean that shortcuts are being taken…ultimately at the expense of your safety.
As the old motto goes and still valid today…you do get what you pay for. The difference is that in illegal cosmetic procedures you may also be buying ineffective outcomes, wound problems, a worsened aesthetic condition and major medical problems.
The popularity of plastic surgery is evident by the near 14 million procedures done in 2011. The vast majority of these improvements did not involve invasive surgery but still accounted for well over a million procedures. Together these numbers mean that roughly 4.5% of the American population had some cosmetic improvement done last year. Using the calculated mean age in the U.S. by the CIA World Factbook of 37 years old (35.6 for males and 38.2 years for females) and assuming that the vast majority of these procedures were done for aging concerns, the percentage of people over age 37 that had some procedure rises to 9%. (14million/155 million)
With nearly 10% of the eligible population participating in cosmetic improvements, it is fair to say that it is a main stream societal occurrence. This is reflected in a study funded last year by the American Society of Aesthetic Plastic Surgery in which it was reported that more than 67% of Americans would not be embarrassed if their friends or neighbors knew they had had a cosmetic procedure. That of course still leaves a third of the people who do not want others to know. In providing cosmetic procedures every day, it sure seems that the number of patients who want to be discreet is much higher than those numbers.
Why are patients desirous of being discreet about cosmetic improvements? Some changes, particularly in facial surgery, are so obvious that it would seem impossible to hide the fact that something was done. Many of the more common non-invasive procedures like Botox and injectable fillers are subtle and discretion is easy. But whether hiding cosmetic changes is easy or hard, some people make great efforts to do it.
I have observed and heard numerous reasons for the stealth approach to cosmetic procedures. One of the most common is economics, one does not want their spouse or family to know they they are spending resources for this seemingly selfish endeavor. That is why Botox and injectable fillers is such a cash business. It is a low cost item compared to surgery that is easy to keep discreet and not be missed. Surgery is a different economic matter but many couples have separate banking accounts. How you hide having a facelift or some form of body contouring surgery is another matter…but I have seen it done more than once.
Insecurity or not wanting to appear vulnerable certainly accounts for many ‘fibs’ that are told. Some would like us to believe that they really did get that better figure by going to countless Zumba classes or have developed a more wrinkle-free face by a great cream or going on vacation. Having a cosmetic procedure is still equated with a sign of weakness or being ‘fake’. Having to submit to a needle or surgery somehow indicates an internal sign of a personality defect or character flaw. As a plastic surgeon I realize that I have a tainted view, but it takes greater strength and constitution to go through surgery and recovery than it is to just let nature takes its course. There is no getting around that beauty is truly painful.
There is also those that simply don’t want others to weigh in on their thoughts about what they are contemplating. It is human nature for someone to tell a prospective patient the most horrid story of what they have heard or read about a certain procedure. Someone somewhere has died or been deformed, they took an eternity to recover or ended up with a bad result. This type of ‘supportive information’ is avoided by being stealthy.
There are many reasons why people are secretive about their cosmetic surgery improvements. Money, insecurity and avoidance of ridicule are the most common ones that I have come to appreciate. I often tell patients that no one else can understand your need if they do not have the same problem. For many ‘run silent run deep’ is the best approach.
Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.