The influx of non–plastic surgeons into the field of aesthetics has been the source of much discussion and concern over the past 15 years. As cosmetic surgery has increased in popularity, so has its prominence in the eye of traditionally noncosmetic practitioners. The number of aesthetic procedures has expanded rapidly over the past decade, as reimbursement for medically necessary treatments continues to contract.1–4 There is considerable pressure on physicians to meet the financial bottom line and the desire to live a comfortable life. These factors are causing an understandable migration into the cosmetic marketplace. Many non–surgery-trained individuals are offering injectable fillers, which do not require a surgeon's skill to administer. Although the presence of these individuals has raised eyebrows, it is difficult to argue that what they are doing is unsafe. There is the possibility, however, that as these providers wade ever deeper into the field of aesthetics they may develop the confidence to offer more than just injections and topical treatments. Of note, D'Amico and associates recently performed a patient survey that found that once a patient establishes a good relationship with a non–plastic surgeon in the receipt of minimally invasive cosmetic treatments, that patient is much more likely to return to that provider for more aggressive treatments.5 Liposuction is one of the most popular aesthetic treatments and has been the focus of much discussion regarding the very real possibility of patient morbidity or mortality when carried out in an inexpert fashion.6–8 We feel that the provision of such a potentially hazardous treatment by physicians with no training in surgery poses a genuine threat to the safety of patients.
To analyze the composition of the current population of cosmetic practitioners, we acquired the names and addresses of all physicians providing minimally invasive Restylane (Medicis, Scottsdale, Ariz.) and Juvéderm (Allergan, Inc., Irvine, Calif.) and invasive cosmetic procedures such as liposuction, breast augmentation, and rhytidectomy. The scope of our search was limited to Southern California, encompassing Los Angeles, San Diego, and the surrounding urban areas. The training background and board certification of all physicians offering cosmetic services in Southern California are detailed fully.
MATERIALS AND METHODS
Providers of Minimally Invasive Procedures
Restylane and Juvéderm were used as markers for providers engaged in the provision of minimally invasive cosmetic treatments. The names and addresses of Restylane providers were provided by the manufacturer, Medicis. The complete list of Juvéderm providers was likewise provided by Allergan. All of the providers in Southern California were then mapped using the ArcGIS geographic information system (Environmental Systems Research Institute, Redlands, Calif.).
Providers of Invasive Cosmetic Procedures
Names and address data of all providers offering invasive cosmetic procedures were gathered from various Web sites9–12 and an Internet search engine,13 using “liposuction procedures” as the key term. As with the processing of the providers of hyaluronic acid fillers, a 120-mile radius encompassing San Diego and Los Angeles was used as the search radius.
Recording of Board Certification and Training Background
Providers of both hyaluronic acid fillers and liposuction techniques were each categorized according to their specialty training using the American Board of Medical Specialties database.14 Board certification of plastic surgeons was confirmed with the American Board of Plastic Surgery.14 Additional verification of medical training was performed with physician curriculum vitae. There were several physicians for whom the board certification specialty was not listed in the American Board of Medical Specialties database, nor was there a curriculum vitae accessible to view on the Internet. These individuals are listed as “unknown.”
Demographic Analysis of the Underlying Population
The numbers of women older than 18 years located in the areas of analysis were extracted from U.S. Census data with the assistance of ArcGIS desktop. Maps depicting the relative concentrations of aesthetic providers were likewise generated with ArcGIS software.
Providers of Hyaluronic Acid Fillers
In Southern California, there are 1867 providers offering hyaluronic acid fillers practicing in 2472 separate geographic locations (Table 1). Some providers have as many as seven practice locations, including practice locations out of state. Overall, the specialty with the largest provider footprint is plastic surgery, with 712 locations for 495 providers. Otolaryngology is the specialty with the greatest number of separate locations for providers, with an average of 1.47 locations per practitioner. This trend to have multiple practice locations is seen across all of the specialties providing hyaluronic acid fillers.
Providers of Liposuction
There are 834 individuals offering liposuction in Southern California, practicing at 1159 separate locations (Table 2). Plastic surgeons remain the number one providers of liposuction, followed by dermatologists and otolaryngologists. The fourth largest group offering liposuction are primary care providers trained in either internal medicine or family medicine. Of note, approximately one in 10 primary care providers offering hyaluronic acid injections also offer liposuction in their practice. Many of these practitioners, board certified in family medicine, run exclusively aesthetic practices. The primary care providers engaged in the cosmetic marketplace are aggressively pursuing market share, with an average of 1.35 practice locations per provider.
Geographic Distribution of Providers and Potential Patients
The geographic extent of this survey is depicted in Figure 1. Each practice location is depicted as a white dot. A density map underlay reveals the highest concentration of providers, which expectedly cluster in the affluent areas of Los Angeles and San Diego. For the sake of these analyses, women aged 18 years and older were selected as the potential patient population. The greatest concentration of providers in Los Angeles falls within the suburb of Beverly Hills. The extreme density of these providers is well illustrated when viewed in the context of the surrounding population. Within the three zip codes that encompass Beverly Hills, there are 19,549 women of the target demographic and 255 providers. In this three–zip code area, there are 77 possible patients per provider. An analysis constrained to the 212 square miles encompassing the epicenter of Los Angeles reveals 692 providers and 752,824 potential patients, with a consequent ratio of 1088 possible patients per provider. A similar analysis encompassing 133 square miles of the San Diego metro area reveals 181 providers and 214,565 possible patients, with a resulting ratio of 1185 patients per provider. An explicit breakdown of the number of potential patients per provider according to zip code within Los Angeles and San Diego can be found in Figures 2 and 3, respectively. The importance of drawing clientele from remote locations to sustain the practice becomes obvious in the context of the intensity of competition focused in these aesthetic epicenters.
The popularity of invasive cosmetic procedures has climbed steadily over the past decade, with liposuction, blepharoplasty, and rhinoplasty procedure categories each annually surpassing the high 200,000s range. The commercial success of these procedures, and the expanding demand for these services as the Baby Boom generation passes into senescence, are understandably the center of a great deal of attention. As managed care has continued to grow, and with the prospect of government-mandated universal care, providers are becoming ever more urgent in their search for alternate sources of revenue. In 2004, Robert M. Goldwyn stated, “… plastic surgery theoretically offer[s] the escape hatch of performing aesthetic surgery that is not financially regulated. This option is usually not available, for example, to pediatricians, pediatric surgeons, most surgeons, most internists, and medical specialists.”15 As we can see from the data collected in this survey of Southern California, lack of training in the surgical arts is no deterrent to providers interested in providing aesthetic services. In an earlier study of the Los Angeles area, it was shown that the number of primary care providers offering hyaluronic acid fillers doubled in the 14-month time span from January of 2008 to March of 2009.16 The training backgrounds of these practitioners offering fillers were incredibly diverse, ranging from family medicine to pathology. As can be seen in this study, the extent of this incursion is not limited to minimally invasive cosmetic treatments but includes invasive, surgical therapies.
There has been much discourse in the literature regarding the basic safety of liposuction, especially when performed in the office setting.6–8,17–19 Although there is no agreement on the complication rate from liposuction, it is well accepted that the procedure is not without risk. The well-trained and conscientious practitioner is duly concerned about the risk this procedure carries of lidocaine toxicity, pulmonary edema caused by fluid shifts, pulmonary embolism, pneumothorax, and perforated viscous. In 2004, guidelines were published by the American Society of Plastic Surgeons committee on patient safety recognizing that liposuction is in fact major surgery. This practice advisory then went on to recommend that to perform liposuction the physician must be trained in a surgical specialty recognized by the American Board of Medical Specialties.20 According to a recently published survey of fatalities caused by liposuction, “The lack of surgical experience was a notorious contributing factor, particularly regarding the timely identification of developing complications.”21 Plastic surgery is the only specialty that requires performance of a minimum of 10 liposuction procedures under attending supervision as a part of residency training. Dermatology also requires exposure to liposuction during residency, with no minimum requirement for cases performed. The remaining specialties have no requirement for hands-on or didactic exposure to liposuction during residency training.
Numerous providers are seeking to expand their provider footprint by practicing at multiple locations. It is not uncommon for the practices to employ physician extenders in the form of nurse aestheticians or nurse practitioners. There are a number of practitioners who have taken a widely divergent path from the traditional practice of medicine, in that they are joining aesthetic franchises that have no association with one particular provider. The development of aesthetic practices where the individual providers are considered to be interchangeable and replaceable is becoming ever more prominent. This is particularly the case among the medi-spas. The practices are often named after a geographic location with a cachet of affluence, such as Rodeo Drive, Beverly Hills, or La Jolla. In these practices, the practitioners are employees of the owner of the clinical facility, and are pushed to produce revenue. The divorce of the practice from the name of the responsible physician has the potential to have a profound impact on the doctor-patient relationship and how patients select a provider. The increasing dependence of aesthetic providers on marketing and advertising is expounded on in depth in a recent letter from M. Felix Freshwater.22 Comparing today's market with the time during which he trained under Ralph Millard, he states, “What is different in 2008? How does the average patient find ‘the best’? - Advertising.”
Although it is somewhat comforting to see that a majority (94 percent) of those providing invasive cosmetic procedures in Southern California have some type of surgical training background, it is disconcerting to see that approximately 40 percent of liposuction practitioners in Southern California had no surgical training in liposuction before entering practice. As it stands now, practitioners originally trained in primary care are the third largest group providing hyaluronic acid injections and the fourth largest group providing liposuction. Training in the use of minimally invasive treatments is both easily obtained and made available to all physicians by eager manufacturers. Liposuction likewise has an ardent contingent offering instructional materials to any physician willing to pay for them. We must question the expanding scope of services that those untrained in surgery are gaining the confidence to offer. The chance of surgical misadventure is high, and the practitioner may find himself or herself in a situation from which extrication (for both physician and patient) to safety may not be possible.
Despite our concern that an unsafe transformation is occurring in the population of cosmetic providers, this trend is unlikely to be addressed in a satisfactory way by legislation. As can be seen from other attempts by the government to regulate medicine and business, it is clear that neither the patient nor the practitioner benefits. In requesting further oversight of cosmetic surgery by the government, we may invite the presence of a guest who may never leave. As famously coined by John Adams, “liberty, once lost, is lost forever.”
In the interest of protecting cosmetic patients, it is imperative that we continue to educate the public on the importance of surgical training in the performance of safe cosmetic surgery. The forces of the free market will favor the superior practitioner.
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