There are few cities in America where the marvels of plastic surgery are more on display than this one. The beaches and bars are walking, breathing billboards for eye jobs and nose jobs, tummy tucks and thigh tucks, new breasts and new chins and feet sculpted to fit better into shoes with unnaturally pointy toes.
But the story of cosmetic surgery here, as in much of America, is not as simple as entering a clinic feeling imperfect and leaving looking beautiful.
In Florida, a state that has been touted as a national example for its regulations on plastic surgery, the statistics clearly illustrate how risky these procedures can be.
In less than two years at least eight people have died here, including a 72-year-old retired postal worker who saved for years to pay for liposuction and a well-known real estate agent who never emerged from a coma after a face-lift.
At one wildly popular clinic, five people have died after surgeries since 1997, and dozens of multimillion-dollar malpractice lawsuits have been filed.
And then there are the scores of profoundly botched jobs: the woman whose doctor went ahead with implants after discovering a potentially cancerous lump in one breast; the patient who ended up a quadriplegic after suffering a heart attack during a face-lift; the homemaker whose bowel was pierced during liposuction who ended up with an infection so severe that her legs had to be amputated.
“I don’t think there is another place in the country where as much surgery is going on–or where as many mistakes are being made and lawsuits are being filed,” said Stuart Ratzan, a Miami attorney who specializes in medical malpractice cases.
That’s not to say that other states don’t have problems. New York and California–also bastions of plastic beauty–have recently seen some high-profile plastic surgeries go wrong.
Manhattan socialite Olivia Goldsmith, who wrote the novel “The First Wives Club” and once mocked those who would go to such lengths to look young, died in January from anesthesia complications at one of New York’s most respected cosmetic surgery clinics. California has revoked the licenses of several doctors found to be performing unsafe surgeries.
But Florida, which tightened its regulations on the surgeries several years ago, prompting a number of other states to follow suit, is considered important to watch for a number of reasons:
The safeguards the state implemented, including the mandatory reporting of deaths and a limit on how long someone can be under anesthesia during plastic surgery, do not seem to have worked. People still are dying and being disfigured on the tables of physicians who have next to no plastic surgery training, and the state’s Board of Medicine again is analyzing what steps it should take to correct the problem and protect consumers.
“The current office surgery limitations may not be enough to protect patients,” Dr. Lisa Tucker, chairwoman of the Florida Board of Medicine, said two months ago when the board announced it was temporarily banning some cosmetic procedures while it investigated their safety.
Millions of procedures
The growing concerns and problems associated with plastic surgery come as the procedures are becoming increasingly popular nationwide. In 1996 there were 696,904 procedures performed in the United States, compared with more than 8.6 million last year, according to the American Society of Plastic Surgeons.
A large portion of that increase stems from non-surgical cosmetic procedures such as Botox injections and chemical skin peels, but more than 1.8 million of the procedures done in 2003 included major, invasive and potentially risky surgery.
“People are so driven to look young, feel young, appear fit, and we have become willing to do virtually anything and risk virtually anything to achieve that end,” said Lynne Luciano, a social historian who studies aging at California State University, Dominguez Hills and wrote the book “Looking Good.”
With what amounts to free advertising from programs such as the hit reality show “Extreme Makeover,” the economics of these surgeries also have shifted dramatically over the past decade. Once considered an option only for the extremely rich, plastic surgery now is accessible to the masses.
Clinics across the country advertise heavily to the middle class; one popular facility in Miami saturates the airwaves during daytime television talk shows and soap operas with ads that promise low monthly payments, no money down and no credit checks.
As a result, some doctors are switching their practices to focus on the lucrative specialty–even if they have little or no education in it. Because most state laws do not apply to the private offices where plastic surgeries increasingly are being performed, and because there are no federal regulations governing which doctors can perform plastic surgery, oral surgeons are doing face-lifts, dermatologists are doing tummy tucks and allergists are giving clients nose jobs.
Essentially, a doctor is a doctor under federal law, and state laws have focused on hospitals and ambulatory care clinics, leaving private doctors’ offices almost completely unregulated.
“The judgment of a physician has been seen as sacrosanct,” said Arthur Levin, director of the Center for Medical Consumers, a New York-based advocacy group. “The government has not wanted to get in a position where it is intervening with the private practice of medicine in the private offices of physicians.”
Two of the principal oversight groups in the field of plastic surgery–the American Board of Plastic Surgery and the American Society for Aesthetic Plastic Surgery–have long advocated minimum standards for physicians who perform cosmetic surgeries. For example, to be certified by the American Board of Plastic Surgery, a doctor has to complete seven years of training, including a three-year residency in general surgery and at least two years of residency in plastic surgery.
License to practice
But being certified as a plastic surgeon is not a prerequisite for performing such procedures in any of the 50 states, so long as the doctor has a license to practice medicine. In California, for example, some studies have estimated that up to 70 percent of oral surgeons also are practicing cosmetic surgery.
“In America you can call yourself a plastic surgeon, hang a shingle outside your door and do these surgeries in your private office operating room with no regulation at all,” said Dr. Rod Rohrich, president of the American Society of Plastic Surgeons and chairman of the department of plastic surgery at the University of Texas Southwestern Medical Center at Dallas. “Most patients don’t know the difference between someone who is certified and someone who’s not.”
Therein, critics say, lies one of the greatest problems. Because of their lack of specialized training, many doctors performing plastic surgery today would not be permitted to operate in reputable hospitals or outpatient surgical facilities. So these doctors instead are performing major, invasive surgery in private offices that often do not have the same emergency resources or expertise that a hospital would if something should go wrong.
Again, certification comes into play. Most clinics do not bother becoming certified by the American Association for Accreditation of Ambulatory Surgery Facilities, the group considered to be one of the gold standards for outpatient surgical safety. Becoming accredited through the association is a long and often expensive process that requires a checklist of compliances that “fills a book you can’t imagine how thick and precise,” said Dr. Robert Bernard, president of the American Society for Aesthetic Plastic Surgery.
“The biggest change may not be how much of this surgery is being performed, but where it is being performed,” said Levin, the consumer advocate. “I don’t think anyone yet knows how big of a problem that might be.”
The reason no one knows the extent of the problem is that no one is keeping a national tally of the deaths stemming from plastic surgery. A few states–among them Florida and California–have begun to, but there are few other states with which to compare the results.
In February, after three high-profile cases in which patients died after having combination tummy tuck and liposuction procedures, Florida decided to act again. It imposed a statewide emergency moratorium banning that double procedure from being performed in doctors’ offices for 90 days while the board studied the safety of such operations.
Time limit on surgeries
But critics say that is not addressing the root of the problem. They worry that one of the biggest risks for patients is how long they are under anesthesia; they would like to see the state lower its current eight-hour time limit on cosmetic surgeries that require anesthesia.
Such critics point out that less-reputable doctors and clinics increasingly offer discounts to patients who have more than one procedure done at once. What often happens is that a patient who comes in for a nose job will decide to have his or her eyes done and tummy tucked. The more procedures the patient undergoes, the longer the patient is under anesthesia.
“The bottom line when you look at what’s going on in Florida is that the one thing you can’t legislate is good surgical judgment and being a good doctor,” Rohrich, of the American Society of Plastic Surgeons, said.
A study released Friday seemed to confirm critics’ fears. The study, done by a dermasurgeon at the University of Cincinnati College of Medicine, concluded that patients were more likely to die from complications related to anesthesia during cosmetic surgery than from surgical error.
A number of states have changed their laws based on the potential risks associated with the use of anesthesia in office settings. Illinois, for example, requires doctors and nurse anesthetists participating in surgeries in offices to have specialized training in anesthesia as well as in advanced cardiac life support.
Liposuction–regardless of how long the surgery takes and whether done in combination with another procedure or not–is among the most dangerous of plastic surgeries. A study done several years ago by two California plastic surgeons estimated that the death rate from liposuction was 1 in 5,000, a rate nearly 20 times higher than that of other forms of elective cosmetic surgery.
The majority of liposuction deaths stem from factors that may be compounded significantly when surgeries are done in office settings. Plummeting heart rates and blood pressure can be deadly when an office does not have emergency equipment nearby. Blood clots–a fear after any surgery–are particularly worrisome because patients go home shortly after surgery without a doctor to monitor them. And because the surgery requires doctors to suction out fat by repeatedly jabbing a suctioning device deep into a person’s body, there is a risk of accidentally perforating vital organs.
Struggle with weight
That happened to Mona Alley, 50, a homemaker from Hollywood, Fla., who had liposuction in 2000. A diabetes patient who struggled with the extra weight around her waist, Alley had heard that liposuction was a good way for people to lose the pounds that can complicate her disease. But during the office procedure, Alley’s intestine was unknowingly pierced, causing toxic waste to spread through her body for nearly two weeks before it was discovered.
Alley’s infection and perforated intestine required extensive surgeries and hospitalizations for the next year. Over time, because she was bedridden for so long, she developed bedsores and circulatory problems–complicated by her diabetes–that required the amputation of both legs.
A lawsuit Alley has filed against the doctor and clinic is pending. The doctor contends that the injury to her intestine could have come from another source and that her circulatory problems stemmed from her diabetes.
On a recent spring day, Alley sat in her wheelchair watching a video of herself before her liposuction. In it she is bowling, wearing a pair of shorts. She smiles when she nails a strike.
“I used to have long, gorgeous legs,” she said.
Alley knows now that consumer advocacy groups recommend that patients check that their surgeon is board-certified, that an office is accredited to perform surgeries and that there are no lawsuits or complaints against the doctor.
Patients also are encouraged to get clearance for surgery from their primary-care physicians, who are more familiar with their medical history. The American Society for Dermatologic Surgery has gone so far as to recommend that patients opt for procedures that do not require general anesthesia to be used in an office setting.
Asked what she would do differently today, Alley is succinct: “I wouldn’t have plastic surgery.”
Her husband, Robert, turns his eyes away from the bowling video and looks at her.
“I told her she was already perfect anyway,” he said sadly.
