Wednesday, March 2, 2011

Medical Tourism - Going Abroad for Discount Plastic Surgery

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Medical tourism refers to patients traveling far from home for plastic surgery, usually to another country, for discounted services or perceived care that cannot be obtained at home. A 2008 survey by the consulting firm Deloitte, estimated that 750,000 Americans traveled abroad for medical care in 2007 and projected that the number would rise to 1.6 million annually by 2012. There is nothing inherently wrong with doing this. I as well as many of my colleagues here in Los Angeles receive patients from many parts of the world such as China, the middle east, Europe, Latin America etc. Although you can find good doctors and appropriate care all over the world as a prospective patient you have to do your due diligence before committing yourself to plastic surgery anywhere be it India, Thailand or even the United States. Surgeon and facility qualifications outside your home country may not be verifiable. Vacation destinations may not have formal medical accreditation boards to certify physicians or medical facilities. The criteria you use to search for a surgeon should not change just because he/she is in a different country. (see my web page how to choose a plastic surgeon) Above all else do not let the price tag blind you to the quality of care. 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.

I recently saw a patient who had breast implants placed in Mexico. Although the implant manufacturer made implants that were FDA approved for use in the USA her specific implants were not. They were only legal in Mexico. Breasts implants at a quarter of the price in your home country may sound to good to pass up but if you do not do your due diligence in researching the care it could end up costing you a lot more than surgery at home. It can even cost you your life.

You should not travel long distances by plane and then have surgery on the day of or day after your arrival. The prolonged time on the plane sitting in one position combined with air pressure changes and the usual travel dehydration puts you at risk for blood clots. Adding surgery to this where you do not eat before surgery, have anesthesia that lowers your blood pressure during surgery and lie still on the operating table for some hours dehydrates you further, stagnates more blood and increases the risk of blood clots even more. After arriving at your destination you need to rehydrate and be active to recirculate your blood for a few days before having any surgery. The same reasoning applies after surgery. Failing to do so can be life threatening if a formed clot passes through your blood stream to the lungs.

There is also an issue of medical clearance for surgery. If you are older and/or taking multiple medications that clearance is best made by the internist who knows you best i.e. subscribes those medications. Anytime a surgeon in any country tries to bypass the issue of medical clearance that is a major red flag indicating you need to find another surgeon.

You have to be especially careful of travel packages that include surgery, air travel, hotel accommodations etc. as an all inclusive package. The agenda of maximizing the number of medical procedures sold to travelers, the possible choosing by the travel agency of substandard surgeons that are cheaper and the selling of procedure(s) prior to an evaluation, examination and planning of surgery or postoperative care by a qualified surgeon is a toxic mix that is sure to lead to complications. Medical tourism is marketed on the basis that health care including plastic surgery can be off-shored like the production of automobiles and electronics or computer technical support call centers. Good medical care involves more than just the mechanical act of surgery. It requires preoperative consultation between the doctor and patient and often times between doctors of different specialties, access to medical records, careful treatment plans, and proper postoperative care. This process can also be hampered by language barriers if the patient does not speak or understand the language of the country in which surgery is performed. The assumption that patients can fly in, undergo surgery right away and then return home after a brief period convalescing in a hospital or hotel for less than a week without any plan for follow-up care is an erroneous one.

A patient that seeks a plastic surgery procedure in another country and leaves without a follow-up can be problematic. A small infection on the plane ride home can turn into a raging infection that lands the patient in the emergency room straight from the arriving airport.

In 2003, women began returning from the Dominican Republic with serious and disfiguring bacterial infections that required months of antibiotic treatment. With nine New York City women infected, the city issued warnings in 2004 against traveling to the Dominican Republic for surgery.

In mid-2010 reports appeared that medical tourism patients were returning to Europe and North America with infections of a NDM-1 strain of bacteria. This resistance was reported to be able to jump between species of bacteria and was resistant to most antibiotics necessitating treatment with a cocktail of antibiotics. The appearance of this resistance may be due to the indiscriminate use of antibiotics in some countries.

A 31-year old Swedish woman responded to a website advertisement by a travel firm specializing in organizing medical treatments abroad. She went to Poland in mid-2010 to have her breast augmentation operation which was performed in an old hospital that was quite different from the modern hospital depicted in the ad. Due to the grave mistakes in anesthetic care and poor postoperative recovery routines, she sustained severe brain injury because of prolonged lack of oxygen. It took more than seven hours to have her transferred to an intensive care unit across the street. 6 months following the operation, she was in a nursing home, in a vegetative state. There is no hope of improvement. Her life and that of her family is ruined.

Research performed by investigative journalists from Swedish national television revealed that there are about ten such firms in Sweden advertising on the web. None of the managers has any medical education. Patients were enticed to believe that the doctors and the facilities abroad had the same technical and safety standards as at home. The travel agent selects the surgeon and the operating facility. It was also discovered that medical records were falsified and the doses of anesthetics and analgesic drugs were altered. Several officials in the hospital management and the Regional Health Commissioner had to resign or were dismissed after this came to light.

In May 2010 a Chula Vista, California woman died on the operating table in Tijuana Mexico while undergoing liposuction of the abdomen. Her doctor was charged with manslaughter by the Mexican authorities who stated that "it was found that the surgeon did not have the documents accrediting him as a plastic surgeon.”

In late 2010 a 20 year old woman flew from London England to Philadelphia for silicone injections to the buttock. These were performed by a non-physician in a hotel room. She returned in early 2011 for more injections but this time the injector nicked a vein in the buttock and the injected silicone traveled up to the lungs and killed the woman. The same procedure by anyone in any country could have ended the same way. There is no FDA approved injectable silicone for that procedure.

In my own experience I am aware of one female body builder who went south of the border to have calf implants placed. She developed an infection that was mistreated or not treated and then had to have her lower leg amputated. Another Persian patient decided to have lip augmentation by a dentist in Iran while visiting relatives there. The material injected was not FDA approved for use in the US. After returning home to California her body reacted to the material and her lips swelled and continued to increase in size till she saw me. Luckily we were able to control the situation with removal of the material and injection of anti-inflammatory medications. Although this intelligent woman would not have done this at home in the US she dropped her guard while in Iran because the price was too good to pass up. That is not to say this could not happen in the US if you are not careful in choosing a surgeon and procedure but at least here you have recourse in the courts and with the state medical boards that license doctors to practice medicine.

Complications can arise just from having too many procedures at one time. Many medical tourism patients are under pressure to do this because they have limited time off work, are tempted to economize and stack procedures to justify the travel time and expense, and are enticed to do so by package deals.

Malpractice is usually harder to prove and has much lower payouts for those having surgery outside the US. If you decide to go that route the AOS Assurance Company can sell you a medical malpractice policy that insures you against complications for procedures performed in accredited hospitals by credentialed physicians. I do not think it covers for surgery in private clinics. The rates are reasonable such as $225 for $100,000 coverage for a facelift and they compensate for lost wages, repair costs, out of pocket expenses, rehabilitation, loss of reproductive capacity and death. is a community website where patients share their experiences in medical tourism including such topics as facility cleanliness, convenience, price, satisfaction, lodging and recuperation.

What about patients who come from outside the US to the US for cosmetic surgery yet have no health insurance here in the US? This is particularly problematic if the patient has a chronic illness or is elderly. Over the years I have had a few cosmetic surgery patients whose recovery was not so smooth because of their chronic medical conditions such as diabetes. This required the input and treatment by other specialists such as internists and that can be costly in the US if you do not have any health insurance here. There are options available for this such as medical complications insurance or medical travel/tourism insurance.

May 20, 2011 addendum:
A 60 year old Arizona woman found a Mexican surgeon online to perform a facelift. She awoke from surgery in pain and felt that things were not healing properly. "My head start to grow 3 times size a human head. I was black and blue, I was scared. I didn't know what to do," she said. The surgeon damaged a salivary gland at some point during her procedure. Because of that, bacteria and saliva began to accumulate in her neck. The company that set her up with her doctor said her issues were a result of her not fully complying with the doctor's orders.

December 28, 2011 addendum:
Australian Plastic Surgeons noted a 38 per cent rise in the number of Australians seeking help after botched cosmetic procedures performed out of the country in 2011 vs. 2010. 81 members of the Australian Society of Plastic Surgeons also found that 62 per cent of bungled surgeries they saw in 2011 were so severely botched that victims would remain "permanently disfigured" and almost 50 per cent could have led to life-threatening complications. Almost 70 per cent of botched jobs were breast related and 15 per cent were facial procedures.

A recent survey of the American Society of Plastic Surgeons (ASPS) conducted by researchers at the Nassau University Medical Center in New York found that 80 percent of the 2-thousand respondents said they had to treat patients with complications following cosmetic procedures conducted in countries other than the US. The majority of those patients developed serious complications due to infection after they returned home. More than half of the medical tourists who underwent breast augmentation or body contouring procedures required multiple operations to correct issues that developed after they returned home.

April 3, 2012 addendum:
Hector Cabral was a plastic surgeon licensed in Dominican Republic who lured Latina women from Manhattan beauty salons where he would examine them and draw surgical markings on their bodies to Santo Domingo for cheap liposuctions in medical tourism that left them near death and permanently disfigured. Some had to be hospitalized for weeks after his surgery. Since he signed the women up in New York but only performed surgery in Santo Domingo he could not be fully prosecuted in the US. After a plea bargain with him pleading guilty to unauthorized practice of medicine Cabral was fined $5,000 and sentenced to 250 hours of community service in the Dominican Republic. He also cannot return to the United States for three years and was ordered to pay $23,000 in total restitution to his seven victims. With such a minimal sentence it is highly likely he will be back and if not New York probably Miami.

July 10, 2012 addendum:
The Office of the Chief Medical Officer in Ireland announced guidelines for patients contemplating cosmetic surgery. For those considering traveling abroad for a cosmetic procedure they are advised to:
  • Check with the regulatory authority in the country to which they intend to travel, to confirm the medical practitioner is appropriately registered in that country.
  • Have consultations the plastic surgeon who will do the procedure and not with a representative from the clinic. In order to ensure that the expected outcome is fully understand.
  • Establish the costs of the procedure and what is included and excluded from these costs, particularly in terms of aftercare and any revision surgery which may be necessary.

November 14, 2012 addendum:
According to a new Ipsos poll of 18,731 adults in 24 countries (Argentina, Australia, Belgium, Brazil, Canada, China, France, Germany, Great Britain, Hungary, India, Indonesia, Italy, Japan, Mexico, Poland, Russia, Saudi Arabia, South Africa, South Korea, Spain, Sweden, Turkey and the United States) the percentage of people that would definitely or probably consider medical tourism by country were:
  • Italy 66 percent 
  • Germany 48 percent 
  • Canada 41 percent 
  • United States 38 percent
For individuals under age 35 the percentages were:
  • India, 86 percent 
  • China 77 percent 
  • Italy 71 percent
People in Japan, South Korea, Spain and Sweden were least likely to be medical tourists.

Various studies using different criteria have estimated that anywhere between 60,000 to 750,000 U.S. residents travel abroad for health care each year, according to the Centers for Disease Control and Prevention.

June 28, 2012 addendum:
The University of Leeds, in the UK, hosted a conference for academics on medical tourism. It was not open to the public. Via the internet there is a multitude of destinations, agencies and clinics that offer what appears to be the same thing... cosmetic surgery on the cheap. An increasing number of countries (India, South Korea, Nicaragua...) are joining in to promote the activity as a means of boosting their economies. The choices for the patient who is spoiled with choices are becoming harder with each passing day. Surveys of UK patients traveling for cosmetic surgery have shown the most popular procedure to be breast augmentation; the next most popular operations were facelift, tummy tuck, liposuction and eyelid surgery. The most popular destinations for British patients were Belgium, Czech Republic, Turkey, Poland and Cyprus. The most important factors in choosing the clinic or surgeon, for these individuals weret: quality of doctor, quality of clinic and price. Only 10% of those surveyed had purchased medical travel insurance before departure. 20% of these individuals expressed dissatisfaction with undergoing cosmetic surgery outside the UK in the areas shown in the following graph.
Here is a flavor of the responses from patients:
Dissatisfaction with doctor and clinic
  • “The so called Doctor was of poor quality , full of his own importance.”
  • “The doctor was inexperienced and a real xxxxxxxx.”
  • "The hospital was in fact little more than a converted house.”
Dissatisfaction with outcome
  • “My nipples were put in the totally wrong place.”
  • “I am leaking fluid and have been on antibiotics due to infection for the last 10 wks”
  • “I was left with a major scar”.
Dissatisfaction with aftercare
  • “I was asked to go home the next morning.”
  • “No aftercare or follow up.”
  • “I was not advised of after care and procedure.”

A third of those surveyed had made their arrangements through an agency or facilitator to aid patient choice, and ensure a safer and hassle -free patient journey. These individuals had a higher level of dissatisfaction than survey participants who did not use an agency or facilitator.

November 15, 2013 addendum:
An increasing number of weight loss surgeries are being performed outside the US as medical tourism because of long (3 year) waiting lists in Canada and denials for coverage (in up to 30% of patients) or lack of health insurance in the USA. An uninsured 455 pound male resident of El Paso Texas recently went down to Juarez Mexico for his weight loss surgery and nearly lost his life. He was a Mexican born Hispanic and had traveled to Mexico for health care all his life. The problems started shortly after surgery with a rapid loss of blood from his drains necessitating a return to the operating room. Lack of nutritional support and leaking of food through his drains then occurred. His condition continued to deteriorate until his family arranged to bring him back to the US. After paying his Mexico hospital bill, they arranged for an ambulance to take him to the US border and another to take him from the border to a US hospital. There he was initially taken to the operating room 3 times a week to wash out his infected abdomen. He was fed only by vein for almost a year before his gastrointestinal tract could be reconnected. Now his family is paying the US hospital regular payments for the money owed.

November 26, 2013 addendum:
Boston health officials are investigating 3 reports of severe infections with Mycobacterium abscessus causing abscesses and drainage from surgical sites in patients who traveled to the Dominican Republic for cosmetic surgery. Other cases have been reported in Maryland, Connecticut, Pennsylvania and New York. All of these patients were part of a group that went to the Dominican Republic during the summer of 2013 for surgery and began having health problems due to the infections earlier this fall after returning home. In the end fifteen cases – all resulting from procedures performed in the Dominican Republic – were identified in five states. All patients were women in the 18-50 age range who had undergone elective procedures that include abdominoplasty, breast surgery and liposuction in the Dominican Republic from April through September in 2013. Symptoms included abdominal abscess, pain, fever and wound discharge. At least nine of the case-patients had surgery at the same surgical center and were attended by the same surgeon which would indicate poor sterilization of surgical equipment.

February 19, 2014 addendum:
An Auckland New Zealand plastic surgeon reported that he recently removed a breast implant from a woman who was infected after she came back from overseas, and the implant said 'sample not for sale'. That overseas surgeon placed an implant that was never meant for human use and was never sterilized by the manufacturer.

March 6, 2014 addendum:
A total of 19 cases of infection from the Dominican Republic have been identified so far. Liposuction was the most common surgical procedure (74%), followed by abdominoplasty (58%) and breast implantation (32%). None of the patients died but 14 (74%) were hospitalized in the United States and underwent corrective surgery as well as prolonged courses of antibiotic therapy. Five received outpatient treatment. The Centers for Disease Control and Prevention notified Dominican public health authorities of the outbreak investigation and recommended patient follow-up and on-site evaluation of infection control practices. The Dominican authorities then temporarily closed the clinic where the procedures were performed.

April 4, 2014 Addendum:

April 18, 2014 Addendum:
MRSA is a bacteria responsible for an increasing number of skin infections in the US both in and outside hospitals. The usual treatment for community, outside the hospital, acquired infections is oral Bactrim, a sulfa based antibiotic. For those allergic to sulfa vancomycin has been a valuable antibiotic but it can only be given intravenously. A report has just come out of a community acquired infection involving an MRSA and vancomycin resistant superbug in Brazil. This is the first time such a bacteria has been encountered and this can affect medical tourism patients.

May 14, 2014 Addendum:
July 10, 2014 Addendum:
Last week a Long Island NY woman died from complications after getting liposuction and a tummy tuck, her three young children and their dad were there. She paid $6,500 wich is less than half of the US price for the procedures. In February 2014 another American woman died after having the same procedure. Both were performed by Dr. Cabral in the Dominican Republic. As I predicted in my April 3, 2012 addendum above he would be back this does not surprise me. Until the authorities in the Dominican Republic do something about this or the American authorities prosecute him for murder this will likely continue.

October 25, 2014 Addendum:
A 24 year old woman from London, England died ealier this month in Bangkok, Thailand after undergoing buttock implant surgery. She returned to the clinic where surgery was performed 2 days earlier with complaints of severe pain. The infected implants were removed after clinic hours and she returned to her hotel where she died. Her surgeon Sompob Sansiri was later arrested and charged with negligence. Severe pain associated with an infection especially of an implant is a sign of deeper spread of infection to the fascia surrounding underlying muscles in the case of skin infections and overlying muscles in the case of implants. These patients need to be hospitalized, urgently taken to the operating room and have all of the involved tissue surgically removed. Frequently more than one visit to the operating room is required to remove the life threatening tissue and close the resulting wound.

April 28, 2015 Addendum:
A 23 year old American woman died in another Dominican Republic medical clinic after an April 2rd liposuction. The clinic is run by Dr. Edgar Contreras, who has been the subject of three other probes by Dominican investigators over the years. The U.S. citizen is the fourth woman and the second American who has died so far in 2015 at Dominican plastic surgery clinics. They include a 35-year-old from Hawaii who authorities say died after a liposuction procedure and a 24-year-old woman who died from an embolism in February 2015 after undergoing surgery to have implants removed from her buttocks. It looks like if you go outside the country for your plastic surgery you definitely need to avoid the Dominican Republic.

June 9, 2015 Addendum:
A 33 year old otherwise healthy woman presented to Gold Coast Hospital in Australia with an 8x6cm (3x2 inch) mass in her right cheek. An MRI showed linear foreign bodies in the mass which was drained of 30cc (1oz) of pus and barbed strands were removed out of the abscess. Mycobacterium abscessus was isolated from the pus.The patient had a thread facelift 6 weeks earlier in Thailand as a medical tourism procedure and was either infected at that time or had contaminated threads placed at the time of surgery. M. abscessus is related to the organisms that cause tuberculosis and leprosy. It is resistant to most antibiotics and can survive extreme environments. It has been isolated from contaminated sinks, instruments, and water in the hospital in a study of medical tourism facilities in the Dominican Republic. Eradication of a M abscessus abscess requires prompt multidisciplinary care, with expedient surgical clearance and prolonged treatment with appropriate antibiotics under the care of an infectious diseases specialist.

August 23, 2015 Addendum:

On March 20, 2015 29 year old Andrea Sarmonikas from Goldcoast Australia decided to have a brazilian butt lift (liposuction and buttock fat graft) in Mexico while vacationing there with her boyfriend. She died during the procedure and an initial autopsy at the hospital where she died found she died from a blood clot blocking an artery in the lungs (pulmonary embolism). They were going to cremate the body and send the ashes back to Australia. The family was not satisfied by the findings and under the advice of the Australian Department of Foreign Affairs went to Mexico where they ordered a second independent autopsy that found she died from internal bleeding and sustained 5 lung punctures during the liposuction. The chief of the Mexican medical forensic department then said that the first autopsy is what happened so it is unlikely that the unqualified surgeon who performed the surgery will be prosecuted. In 2014 an American woman died after undergoing a tummy tuck by the same Mexicali, Mexico surgeon.

April 17, 2017 Addendum:
In mid-2016 Ms. N went to the Dominican Republic for a Brazilian butt lift (fat grafting) and breast augmentation. She returned home to Boston a week later and began to drain thin fluid from her incisions and new leg bruises that became open wounds. She became fatigued falling asleep by 5pm and lost weight without trying to do so. By a month after her surgeon her breast implants became exposed and had to be removed. After seeing multiple doctors, taking multiple antibiotics and having multiple procedures she saw an infectious disease specialist in August 2016. After multiple tissue cultures he diagnosed atypical mycobacterial infection requiring months of antibiotic therapy. Her medical care became so consuming that she lost her job. She had this surgery there despite publicized cases of these infections going back to 2013 and The Centers for Disease Control and Prevention actions regarding such infections in 2014. The money you save up front can cost you severely with interest on the back end especially since most us health insurance policies do not cover complications from cosmetic surgery.

June 27, 2017 Addendum:
8 female New Yorkers and 2 women from Connecticut between the ages of 28 and 39 underwent cosmetic surgery between March 2 and April 27, 2017 in the Dominican Republic, 8 at the same facility in Santa Domingo. They developed Mycobacterium abscessus/chelonae infections and required hospital admission in the US for surgical removal of infected tissue and weeks of IV antibiotics. One of these women, 40 year old, Linda McFaline of the Bronx went there to get liposuction and replace her 10 year old breast implants. She described a waiting room with 30 women waiting for surgery and an 11:30pm surgery. By the time she arrived back in New York she had a 105 degree fever, within 72 hours her breasts were read despite taking oral antibiotics. Her New York surgeon removed the implants leaving her with open wounds. After a 2 month hospital stay she was sent home on an 8 month course of intravenous antibiotics. The Dominican Republican surgery cost $5,300 but removing the implants cost her $10,000 and she will need additional surgery at additional costs.

In response, the New York City Department of Health issued a health alert, urging anyone who developed a skin infection after undergoing cosmetic surgery in the Dominican Republic to seek medical care right away and a warning against so-called “lipotourism,” or traveling to other countries for plastic surgery at a fraction of what it would cost in the U.S.. Doctors who see patients with symptoms similar to those of Mycobacterium abscessus/chelonae are asked to report them to the city health department.

Center for Disease Control and Prevention medical tourism webpages
Medical Tourism - Getting Medical Care in Another Country
The Pre-Travel Consultation Counseling & Advice for Travelers
Medical Tourism - Getting Medical Care in Another Country

How to Find and Choose a Plastic Surgeon

Aaron Stone MD - twitter
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