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Physicians Update


Physicians Update

Fall 2006: Plastic Surgery

Managing Expectations for Cosmetic Surgery Critical for Both Patients and Physicians

If you ever want confirmation that Los Angeles indeed is a Mecca for body makeover, just open the L.A. Weekly newspaper. In one recent issue, 19 advertisements for cosmetic-surgery centers offered lifts, implants, tummy tucks, liposuction, Botox injections, facial fillers and a variety of laser rejuvenation procedures.

Los Angeles is a microcosm of what is happening nationwide. According to the American Society for Aesthetic Plastic Surgery (ASAPS), nearly 11.5 million surgical and non-surgical cosmetic procedures were performed in the United States in 2005, with patients spending approximately $12.4 billion. Since the Society began collecting statistics in 1997, the overall number of cosmetic procedures has increased 444 percent.

In such a competition-charged milieu, patients must become critical and informed consumers when selecting a cosmetic surgeon. A patient should never be intimidated about asking questions, and should not hesitate to verify a potential surgeon’s credentials and board certification, says Timothy A. Miller, M.D., chief of the Division of Plastic and Reconstructive Surgery at UCLA. “Ask about the surgeon’s training. Ask how many times they have done the procedure, and about any complications. Ask for referrals. Discuss the risks of the procedure.”

Patients often don’t understand that cosmetic surgery—as opposed to plastic surgery—is not a specialty recognized by the American Board of Medical Specialties (ABMS). Just because a physician claims to be “board certified” doesn’tmean he or she has had sufficient training in cosmetic surgery; certification could come froman unrecognized, selfdesignated board that requires little more than an application fee.

On the other hand, “any plastic surgeon certified by the American
Board of Plastic Surgeons who does a fair amount of reconstructive surgery is going to be very much at ease doing cosmetic surgery,” Dr. Miller says. “A tremendous amount of overlap exists between plastic reconstructive surgery and cosmetic surgery,” notes UCLA plastic and reconstructive surgeon George H. Rudkin, M.D. “Reconstructive surgery is very complimentary to cosmetic surgery.”

In fact, the American Board of Plastic Surgeons states that “cosmetic surgery is an essential component of plastic surgery. The plastic surgeon uses cosmetic surgical principles both to improve overall appearance and to optimize the outcome of reconstructive procedures.”

The trend over the past several years has been toward lessinvasive cosmetic procedures such as Botox® injections, laser rejuvenation, chemical peels and fillers. According to the ASAPS, 9.3 million non-surgical procedures were performed in 2005. Botox injection was the most sought-after procedure, followed by laser hair removal, fillers, microdermabrasion and chemical peel. Among the 2.1 million cosmetic surgical procedures last year, liposuction was performed most often, followed by breast augmentation, eyelid surgery, rhinoplasty and abdominoplasty. UCLA’s cosmetics practice cites similar patterns.

Some newer procedures offer alternatives to such traditional surgeries as the facelift. One is the thread lift, which may be an option for patients who want lifting and tightening of their cheeks, mid-face, jowls or eyebrows without undergoing major surgery. The thread lift, performed under local anesthesia as an outpatient, takes about one hour. The procedure is done percutaneously, requiring no large incisions, and often is used in conjunction with Botox for fine wrinkles, dermal fillers for deeper wrinkles, and skin treatments such as peels or thermage.

The cosmetic-surgery market has expanded beyond women. “Less of a stigma exists now for men to come in for a cosmetic procedure,” says Dr. Rudkin. Some techniques have been adapted for men. For example, the platysma plictation procedure with Zplasty closure to remove excess skin from the neck was designed specifically for men. The operation is designed to hide scarring, can be performed under local anesthesia, and patients may return home the same day.

While some patients view cosmetic surgery as something less than surgery, it is surgery and carries attendant surgical risks. “Some people, I think, look on it as a step above going to a beautician or getting their nails done,” says Andrew Da Lio, M.D., UCLA plastic and reconstructive surgeon.

Most cosmetic procedures currently are performed in office-based facilities— 48.3 percent in 2005, according to the ASAPS — or in freestanding surgicenters (27.9 percent). Hospital-based procedures accounted for 23.8 percent of the procedures. But unlike office settings or surgicenters, a hospital setting can provide the broadest umbrella of quality care, with boardcertified surgeons and anesthesiologists, high-quality nurses and excellent recovery facilities. And unlike surgeries performed in an office or surgicenter, patients who receive cosmetic surgery in a hospital such as UCLA Medical Center are able to stay overnight for recovery and observation, adding an extra measure of safety.

Clarifying why someone elects to have cosmetic surgery is as important for the physician as it is for the patient. “The best motivation for cosmetic surgery is a healthy sense of vanity—emphasis on the word healthy,” says Dr. Miller. “There is nothing wrong with vanity, but when it becomes obsessive or the patient sees it as an avenue to changing the direction of his or her life, it can be a problem.”

Patient expectations can stretch beyond reason. “If you expect cosmetic surgery to turn you into a movie star, you’re bound to be disappointed,” Dr. Miller says. “Also don’t count on surgery to save a rocky relationship, gain a promotion or improve your social life.”

Just as the patient must be realistic about his or her desires, the surgeon must be upfront with patients about what is achievable. “It is important to be very honest about the kind of outcome a patient can expect, and not to promise something that is not achievable,” says Dr. Da Lio.

Once trust has been established between the surgeon and patient, the complementary task of working together toward achieving the most flattering results can begin. “There’s nothing wrong with trying to look good,” Dr. Da Lio notes, “as long as it is within reason.” Overall, UCLA cosmetic surgeons strive to create a natural aesthetic balance. “We don’t want to pull a face as tight as we can so you could bounce a coin off the patient’s cheek,” Dr. Miller says. “That is not good cosmetic surgery.”

Rather, the most successful surgeries can be the ones that are the least obvious. “Good cosmetic surgery should make the patient look refreshed without being obvious,” says Dr. Rudkin. And Dr. Da Lio adds that the ultimate compliment a cosmetic surgeon can receive is for patients to report that people have commented they look better and restored, but can’t quite identify why.

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