As cosmetic surgery becomes more mainstream and patients become better educated, it seems that most patients know to look for a board-certified plastic surgeon or a member of the American Society of Plastic Surgeons when researching for a prospective doctor. But what is a "board-certified plastic surgeon" exactly? With all the "cosmetic surgeons," "dermatologic surgeons," "facial surgeons," "oculoplastic surgeons," and "cosmetic doctors" advertising their services, it can get confusing. Here's what you need to know...
Board-Certified Plastic Surgeon
The only medical board that governs and certifies plastic and reconstructive surgeons is the American Board of Plastic Surgery. Each area of medicine, including plastic surgery, general surgery, internal medicine, obstetrics and gynecology, emergency medicine, family practice, dermatology, ENT, and ophthalmology, to name a few, has their own governing body that certifies members of that specialty. While, legally, any licensed physician can practice any type of medicine and even perform any type of surgery, only physicians certified by the American Board of Plastic Surgery have successfully completed an approved educational program and an evaluation process designed to assess the knowledge, experience, and skills required to provide high quality patient care in the area of plastic surgery. Physicians who have received training in other medical specialties (e.g. ophthalmology, family practice, Ob-Gyn, general surgery, etc...) and are now performing plastic surgery procedures as part of their practice, may be certified by their respective medical board, but are not eligible to be board-certified plastic surgeons.
To be certified by the American Board of Plastic Surgery, a physician must first graduate from an accredited medical school and complete at least five years, but often up to seven years, of additional training in general and plastic surgery as a resident surgeon in a program accredited by the Accreditation Council for Medical Education or the Royal College of Physicians and Surgeons of Canada. After completion of medical school and the additional years of specialized surgical training, with emphasis on plastic and reconstructive surgery of the face, breasts, abdomen, trunk, extremities, and hands, physicians are then able to apply for certification by the American Board of Plastic Surgery. To become certified, the physician must finally pass comprehensive written and oral examinations, administered by expert members of the American Board of Plastic Surgery. This entire process, which takes at least seven to nine years after graduating from college, is what distinguishes a board-certified plastic surgeon, certified by the American Board of Plastic Surgery, from every other physician who performs various cosmetic procedures.
American Society of Plastic Surgeons
After becoming certified by the American Board of Plastic Surgeons, physicians are eligible to become members of the American Society of Plastic Surgeons (ASPS), the world's largest and most respected organization of plastic and reconstructive surgeons. To become members of the American Society of Plastic Surgeons, board-certified plastic surgeons must demonstrate expertise in all areas of plastic surgery, including cosmetic and reconstructive surgery of the face, breast, body, and extremities. Additionally, members must adhere to a strict code of ethics, operate only in accredited, safe medical facilities, and meet yearly continuing medical education requirements. Membership into the ASPS is bestowed only upon the most elite members of the plastic surgery community with the hopes that members will continue to make advances in the field of surgical technique, patient care and safety, ethics, and plastic surgery research.
Reputation and Relationship
After assuring that a prospective plastic surgeon is certified by the American Board of Plastic Surgery and a member of the American Society of Plastic Surgeons, it is important to feel comfortable with his/her reputation and the physician-patient relationship that is formed. Patients must feel comfortable enough with their plastic surgeon to ask for information, answer questions, and have an open line of communication for months, if not years, to come.
While there is no magic formula for selecting a plastic surgeon and no guarantee of results, selecting a plastic surgeon that is certified by the American Board of Plastic Surgery, a member of the American Society of Plastic Surgeons, and has a reputation as a skilled and confident surgeon will maximize chances of surgical success.
Selecting a Surgical Facility
After selecting a plastic surgeon, where to have the surgery performed may be the most important decision a patient has to make when considering plastic surgery. As physicians certified by the American Board of Plastic Surgery, members of the American Society of Plastic Surgeons (ASPS) may only operate in the safest, cleanest, and best-accredited facilities in the country. These high standards ensure that all facilities where this select group of plastic surgeons operates have an excellent safety record and are equipped to handle any case, no matter how big or small, a plastic surgeon might perform.
We Are Accredited
An accredited surgical facility, whether it is an office-based operating room, an outpatient surgical center, or a hospital setting, is one that must meet strict national standards for proper surgical equipment, operating room safety, nurses, anesthesiologists and nurse anesthetists, and surgeon credentials.
To be considered an accredited facility, every surgical site where an ASPS member operates must be inspected and approved by one of the following national governing boards:
To be considered an accredited facility, surgical centers must adhere to strict principles governing patient safety guidelines, those that operate and provide care in the facility, and sanitation. Accredited facilities must:
- Allow only board-certified or board-eligible surgeons to operate
- Allow only board-certified or board-eligible anesthesiologist or certified nurse anesthetists to administer anesthesia
- Employ only certified surgical technicians, registered nurses, and licenses practical nurses who are trained in the practices of Advanced Cardiac Life Support (ACLS)
- Adhere to all local, state, and national sanitation, fire safety, and building code regulations
- Adhere to federal laws and Occupation Safety and Health Administration (OSHA) regulations, including blood-borne pathogen protection and hazardous waste disposal standards
- Practice advanced patient monitoring during and immediately after surgery
Advantages of Accredited Facilities
Research has shown that accredited ambulatory surgery centers have higher safety standards and better safety records than non-accredited facilities. Accredited surgical facilities have an extremely low rate of serious complications (i.e. less than 0.5%) and an even smaller mortality rate (i.e. 0.00001%) when compared with non-accredited facilities.
Many accredited surgical centers are also equipped to recuperate patients overnight if the need arises. These facilities have at least two licensed staff members, one with ACLS training, on site at all times with access to emergency safety equipment and medications. These facilities and staff have clearly defined safety plans implemented in the event that a patient requires transfer to a hospital setting.
American Society of Plastic Surgeons
Physicians performing procedures in non-accredited facilities have no governing board or oversight committee inspecting their equipment, safety standards, sanitation measures, or qualifications of the operating room staff. While physicians who are not certified by the American Board of Plastic Surgery and are not members of the American Society of Plastic Surgeons may choose to perform surgery in non-accredited facilities, such as their office examining room, ASPS members may only operate in accredited facilities, ensuring optimal patient safety and outcome.
Before undergoing any procedure requiring anesthesia, it is advised that patients check the credentials of the proposed surgical facilities. Accreditation may be confirmed at the following organizations' websites:
Medical tourism (a.k.a. medical travel, health tourism, global healthcare) is the term given by travel agencies and the media to describe the practice of traveling internationally in the search of healthcare or healthcare providers traveling internationally to deliver healthcare for profit. While the majority of patients traveling internationally seek elective surgical procedures such as cosmetic surgery, joint replacement, or dental surgery, virtually every type of medical, surgical, or even psychiatric care is available abroad.
Increase in Medical Tourism
With rising healthcare costs in the United States, an increasing demand for plastic surgery, sophisticated global marketing campaigns, and patients' ever-growing desire for cost savings, it is no wonder that medical tourism, particularly for patients seeking cosmetic surgery, has grown so rapidly over the last decade. Due to the downturn in the economy, the most recent statistics from 2008 show that the number of cosmetic surgery procedures performed in the United States has decreased by 9%, while the number of cosmetic surgery procedures performed on Americans traveling abroad has tripled.
Evidence shows that patients seeking cosmetic surgery procedures abroad are most influenced by marketing schemes that promise personalized care delivered by U.S.-trained physicians at significantly reduced prices. These packages often include extras such as tourist attractions, spa features, transportation, and accommodations. The most popular travel destination for American medical tourists are Argentina, Bolivia, Brazil, Colombia, Cuba, Mexico, and Turkey. These destinations are chosen mostly for their proximity, vacation potential, and seeming abundance of qualified plastic surgeons.
Risks of Medical Tourism
Because there is no single organization that governs international plastic surgeons, surgical facilities, and postoperative care, those physicians and centers performing cosmetic surgery abroad are not held to the same high, meticulous, and consistent standards of those in the United States. With that said, there is also no formal way of confirming the claims of physician training, facility accreditation, postoperative care, safety standards, and sterility measures made by those advertising internationally.
Specifically, surgeons and anesthesiologists trained abroad do not undergo the same standardized education and surgical training requirements as those in the United States (click to learn about Selecting a Plastic Surgeon). Additionally, the facilities where surgery is performed abroad may not be held to the same standards as those accredited in the United States (click to learn about Selecting a Surgical Facility). Most alarmingly, however, is the possible lack of ancillary departments, intensive care units, properly screened blood products, and medical services available for handling intraoperative or postoperative emergencies, should they arise. Finally, given the nature of medical tourism, routine follow-up and evaluation and treatment of potential postoperative complications are not possible once the patient returns to the United States.
Legal and Ethical Issues
An additional concern for patients considering medical tourism is the lack of legal recourse if intraoperative or postoperative complications are encountered. The limited nature of litigation in various other countries is one reason for the lower cost of medical care abroad. If problems arise, patients may not be covered by personal insurance and may be unable to seek compensation via malpractice lawsuits.
Additionally, physicians outside of the United States are not required to be compliant with the Health Insurance Portability and Accountability Act (HIPAA), which ensures personal patient information security, or to keep uniform medical records.
Before considering undergoing a cosmetic surgical procedure outside of the United States, patients must gather as much information as possible. Questions to consider include:
- Is the surgeon and anesthesiologist qualified?
- Are the medical facilities supplied with proper instruments, implants, blood products, and emergency equipment?
- How will routine follow-up and complications be handled?
- What legal recourse or personal insurance is available in the event of a serious complication?
- Do the physicians keep adequate medical records in accordance with HIPAA standards?
- Are return travel and vacation activities compatible with the planned surgery?
In short, before traveling abroad for any medical procedure, patients should do proper research on the advertised physician and facility, take time to consider all options, and gather enough information to make a rational, safe decision.
Psychological Aspects of Plastic Surgery
As the number of patients undergoing plastic surgery procedures increases, up to nearly 1,500,000 in 2008, so too do patient expectations regarding postoperative results. Evidence shows that patients with unrealistic preoperative expectations, either in regards to anticipated physical or social alterations, are the least satisfied with their postoperative results.
Just as it is important for patients to be aware of their preoperative expectations, surgeons must also be aware of their patients' desired aesthetic goals and the resulting effects on emotional well-being. Traditionally, plastic surgery outcomes were described by surgeons only in terms of a complication-free result and the aesthetic effects of the surgery. However, current research shows that patients are equally concerned with their postoperative changes in body image and with obtaining positive improvements in their quality of life following cosmetic surgery procedures.
In order to improve patient satisfaction, patients and surgeons alike benefit from understanding the preoperative and postoperative psychological aspects of plastic surgery.
Preoperative Patient Expectations
The single most determining factor regarding postoperative patient satisfaction for those undergoing a cosmetic surgical procedure is preoperative expectations. Similarly, patients with unrealistic and unmet preoperative expectations are those most likely to be dissatisfied with their surgical results and experience a negative impact on their emotional well-being. To combat postoperative dissatisfaction, it is imperative that patients be well informed and emotionally prepared prior to undergoing any plastic surgery procedure.
The physical expectations associated with plastic surgery are perhaps the easiest to address and correct preoperatively. Regardless of the procedure being considered, perfection and absolute, unchanging symmetry does not exist in the human body and is not attainable through plastic surgery. Similarly, even very pleasing postoperative results will not remain permanently satisfactory given the unavoidable effects of aging, weight loss or weight gain, and pregnancy. For instance, augmented breasts will eventually sag and loose superior fullness just as unaugmented breasts will. Thus, patients must consider how much imperfection and uncertainty they are willing to accept given the amount of time, money, and pain that will be encountered. A thorough and honest conversation with the plastic surgeon will help to alleviate any unfounded preoperative hopes or ideals.
More difficult to identify and manage are unrealistic preoperative psychological expectations. Plastic surgery has been shown to have a positive impact on self-image and postoperative quality of life, but has absolutely no effect on basic personality, personal interactions, or sources of stress. Specifically, patients expecting to undergo a dramatic change in personality (e.g. from wallflower to extreme extrovert), improve or attract a romantic relationship, erase the pain of past teasing, or finally achieve "perfection" are not candidates for plastic surgery. A thorough understanding, by both the patient and the surgeon, of the patient's motivation for undergoing plastic surgery is vitally important prior to any type of surgical intervention.
Body Dysmorphic Disorder
While all patients seeking cosmetic surgery have some degree of body image dissatisfaction, those with extreme dissatisfaction with their appearance may suffer from body dysmorphic disorder. Research suggests that 1-2% of the general population suffers from this disorder, while up to 7-8% of patients seeking plastic surgery may be affected. Because of the higher rate of this disease in potential cosmetic surgery patients, surgeons and patients alike need to be aware of the symptoms, potential problems, and methods of treatments for people who suffer with this illness.
The diagnostic criteria for body dysmorphic criteria include the following: 1) a preoccupation with an imagined or slight defect in appearance, 2) extreme concern over a slight defect in appearance, and 3) distress or impairment of daily functioning secondary to preoccupation with an imagined or slight defect in appearance. For example, a person that is so distracted or concerned by the appearance of their relatively normal nose that they look at themself in every mirror available, make countless attempts to camouflage the perceived defect, refuse to participate in social or romantic relationships, or have lost their job due to this preoccupation may have body dysmorphic disorder.
Studies suggest that patients with body dysmorphic disorder who seek out and undergo cosmetic surgery to "fix" their perceived "problem" typically experience no change in, and may even worsen, symptoms of body dysmorphic disorder. Only 3.6% of patients with body dysmorphic disorder that undergo surgery experience a positive impact following cosmetic surgery, compared to a nearly 80-85% satisfaction rate in the general population. Additionally, patients with this disorder may shift their focus of concern to another body area following surgery on an initial site of dissatisfaction.
Because of the extraordinarily low satisfaction rate amongst patients with body dysmorphic disorder, and a propensity for violence against themselves and others following surgical intervention, body dysmorphic disorder is considered a contraindication to plastic surgery. Evaluation by a psychiatrist, psychotherapy, and pharmacotherapy are the only interventions that have been found effective at relieving the symptoms of this difficult disease.
Immediate Postoperative Patient Expectations
Immediately following plastic surgery, it is not uncommon for patients to experience a bout a post-surgical depression. Not unlike the "baby blues" that some women experience following the birth of a child, some patients feel temporary bouts of regret, disappointment, anxiety, or sadness following a cosmetic surgery procedure.
Given the years of financial saving, anticipation, and excitement often endured prior to undergoing a plastic surgery procedure, it is understandable that a patient may feel less than ecstatic when they wake from anesthesia. First of all, it is often confusing to view such a drastic, or maybe not so drastic, change in appearance following a cosmetic procedure. It takes time for the patient to feel comfortable viewing their new reflection in the mirror each morning. Additionally, the postoperative effects of pain, anesthesia, and medication may leave certain patients feeling weak, drained, lethargic, or groggy that can be interpreted as feelings of depression. These feelings are compounded by the fact that patients must often refrain from physical activity, exercise, and sex, resulting in the additive feelings of restlessness, boredom, and helplessness. Finally, following cosmetic surgery, patients are often bruised, swollen, and have visible sutures or bandages that can be disheartening and even scary if they then longingly recall their unbruised, unbandaged, "normal" preoperative appearance.
To combat this possible side effect of plastic surgery, it is important for all patients to remember that the postoperative discomfort, disfigurement, and anxiety is temporary. The best ways to prevent these feelings from becoming pervasive are to have a strong support in place, set up a "recovery station" with the essential magazines, snacks, and blankets prior to surgery, follow the surgeon's instructions, and be patient with the healing process. It may take several weeks, if not months, before the final postoperative result is visible and patients should be gentle and forgiving with themselves while they adjust to their new look.
Long-Term Postoperative Patient Expectations
Despite the potentially long and arduous course that patients must endure prior to achieving their final outcome, the vast majority of patients, approximately 85% of those undergoing plastic surgery, are satisfied with their results and would undergo the procedure again. Statistics show that patients undergoing cosmetic surgery benefit from an improvement in body image and a subjective improvement in their quality of life. A person with a high quality of life is generally considered to have good health, satisfactory relationships, psychological well-being, and appropriate social and sexual functioning. Specifically, in a recent study examining plastic surgery patients one and six months postoperatively, it was found that patients reported an increase in self confidence, improved satisfaction with their appearance, less dissatisfaction with their weight, and positive changes in social, sexual, and interpersonal relationships while enjoying more leisure activities. That being said, it is not surprising that the vast majority of the patients evaluated in this study had adequate support systems in place prior to and following surgery.
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