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In Defense of Ambulatory Surgery and the Plastic Surgeon in Private Practice

Swanson, Eric, M.D.

Plastic and Reconstructive Surgery: August 2016 - Volume 138 - Issue 2 - p 385e–386e
doi: 10.1097/PRS.0000000000002394

Swanson Center 11413 Ash Street Leawood, Kan. 66211

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Yuan and Chung1 suggest that “health care should be viewed as a process among multiple groups of specialists,” modeled after industrial methods that use “precise process control methods to minimize procedural variability and enhance efficiency.” Specific examples of such methods and how they may be applied to our specialty are lacking.

The authors1 cite Toyota Motor Corporation’s corporate objectives of an “engaged, problem-solving workforce to innovate and stay ahead of the competition” and “building people before building cars.” Similar platitudes may be found in the mission statements of countless companies. Assembly lines do promote uniformity and efficiency. Using Toyota’s example, Tebbetts2 defined each and every surgical step of a breast augmentation, reducing his average operating time to 24 minutes (a time Henry Ford would no doubt find satisfactory). However, few surgeons embrace a cookie cutter approach to surgery.3 Plastic surgery is not a product; our business is patient care, not manufacturing. The corporate business model is misapplied to plastic surgery.4

Traditionally, morbidity and mortality rates, and readmission or reoperation rates, have been used as quality indicators in surgery.5 , 6 There is less need for the patient’s input regarding the result of a cholecystectomy; a recovered patient without a complication counts as a success. Plastic surgery is different.5 , 6 Patient satisfaction with the aesthetic result is often the objective, and one that cannot be adequately measured using complication and reoperation rates alone.5 Measurements and patient-reported outcome data are needed.5

The authors1 comment that ambulatory health care is “problematic,” “improving at a much slower rate than hospital-based care,” and “prone to problems and errors.” They do not present data to support such an opinion. The authors reference a government Web site7 that states, “Hospitals often have more infrastructure to improve quality and to respond to performance measurement compared with providers in other settings.” The frequency of errors in hospitals was highlighted in the well-known 1999 report by the Institute of Medicine.8

Today, most plastic surgery takes place in ambulatory surgery centers or accredited office surgery facilities rather than hospitals.9 This transition resulted from the improvements in surgery and anesthesia methods referenced by the authors.1 , 6 Although studies of complication rates in plastic surgery patients may actually favor the ambulatory setting,10 , 11 the comparison is unfair because patients treated in the community are typically healthier, and undergoing less complicated procedures, than patients treated in hospitals. Elective plastic surgery patients usually do not need the hospital “infrastructure,” relieving pressure on hospitals, and greatly reducing the cost (and increasing the availability) of health care.

Some may believe that the days of the plastic surgeon in solo practice (“carrying his black bag”1) are numbered. On behalf of plastic surgeons in solo private practice, I beg to disagree. It is not clear that abandoning the patient-physician relationship (not patient-physicians) in favor of a patient-team relationship is really in the patient’s best interest. Important advances have been made by plastic surgeons in private practice, including the transition to vertical mammaplasties.12 One advantage of private practice is greater freedom to implement quality improvements. An example is total intravenous SAFE (spontaneous breathing, avoid gas, face up, extremities mobile) anesthesia.13 Surgeons in academic practice may find this conversion impossible because their anesthesia providers use general endotracheal anesthesia.14 Some of my academic colleagues inform me that ultrasound surveillance for deep venous thrombosis detection is simply not possible because their division or department would be unlikely to approve the expense. Many plastic surgeons find themselves forced to use hospital-mandated risk-assessment models and order chemoprophylaxis.14 Indeed, changing the status quo can be difficult in institutions—someone will always object. Academic medicine is not synonymous with evidence-based medicine.

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The author has no financial interest to declare in relation to the content of this communication.

Eric Swanson, M.D.

Swanson Center

11413 Ash Street

Leawood, Kan. 66211

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1. Yuan F, Chung KC. Defining quality in healthcare and measuring quality in surgery. Plast Reconstr Surg. 2016;137:1635–1644.
2. Tebbetts JB. Achieving a predictable 24-hour return to normal activities after breast augmentation: Part 1. Refining practices by using motion and time study principles. Plast Reconstr Surg. 2002;109:273–290; discussion 291–292.
3. Spear SL. Achieving a predictable 24-hour return to normal activities after breast augmentation: Part 1. Refining practices by using motion and time study principles (Discussion). Plast Reconstr Surg. 2002;109:291–292.
4. Swanson E. The commercialization of plastic surgery. Aesthet Surg J. 2013;33:1065–1068.
5. Swanson E. Levels of evidence in cosmetic surgery: Analysis and recommendations using a new CLEAR classification. Plast Reconstr Surg Glob Open 2013;1:e66.
6. Chung KC, Rohrich RJ. Measuring quality of surgical care: Is it attainable? Plast Reconstr Surg. 2009;123:741–749.
7. Agency for Healthcare Research and Quality. Highlights from the 2011 National Healthcare Quality and Disparities Report. Available at: Accessed January 24, 2016.
8. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. 1999.Washington, DC: National Academy Press.
9. Haeck PC, Swanson JA, Iverson RE, et al. Evidence-based patient safety advisory: Patient selection and procedures in ambulatory surgery. Plast Reconstr Surg. 2009;124:6S–27S.
10. Winocour J, Gupta V, Ramirez JR, Shack RB, Grotting JC, Higdon KK. Abdominoplasty: Risk factors, complication rates, and safety of combined procedures. Plast Reconstr Surg. 2015;136:597e–606e.
11. Gupta V, Winocour J, Shi H, Shack RB, Grotting JC, Higdon KK. Preoperative risk factors and complication rates in facelift: Analysis of 11,300 patients. Aesthet Surg J. 2016;36:1–13.
12. Hall-Findlay EJ. A simplified vertical reduction mammaplasty: Shortening the learning curve. Plast Reconstr Surg. 1999;104:748–759; discussion 760.
13. Swanson E. The case against chemoprophylaxis for venous thromboembolism prevention and the rationale for SAFE anesthesia. Plast Reconstr Surg Glob Open 2014;2:e160.
14. Iorio ML, Davison SP. Reply: Practical guidelines for venous thromboembolism chemoprophylaxis in elective plastic surgery. Plast Reconstr Surg. 2015;136:393e–394e.
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