Plastic Surgery Medical Tourism in Colombia: A Review of 658 International Patients and 1,796 Cosmetic Surgery Procedures : Plastic and Reconstructive Surgery – Global Open

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Plastic Surgery Medical Tourism in Colombia: A Review of 658 International Patients and 1,796 Cosmetic Surgery Procedures

Campbell, Christopher Alexander MD*,†,‡; Restrepo, Carolina MD*,†,‡; Navas, Genesis MD*; Vergara, Ileyna MD*; Peluffo, Laura*

Author Information

From the *Premium Care Plastic Surgery, Cartagena, Colombia

†Penn State Hershey Medical Center, Hershey, Pa.

‡Operation Smile, Virginia Beach, Va.

Published online 16 May 2019.

Received for publication September 6, 2018; accepted March 1, 2019.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

Supplemental digital content is available for this article. Clickable URL citations appear in the text.

Christopher Alexander Campbell, MD, Premium Care Plastic Surgery, Carrera 3, No 4–21, Bocagrande, Cartagena, Colombia, E-mail: [email protected]

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Plastic and Reconstructive Surgery - Global Open 7(5):p e2233, May 2019. | DOI: 10.1097/GOX.0000000000002233

Abstract

INTRODUCTION

Medical tourism is the rapidly growing practice of traveling across international borders to obtain healthcare. Research has shown that the number of patients traveling abroad for medical services is increasing, with an estimated 14–16 million patients worldwide (1.4 million from the United States alone) seeking medical care abroad every year.1 The demand for more advanced, quality and cost-effective healthcare services, coupled with modern technologies in transportation and communication, are major factors driving growth for the global medical tourism industry. According to a recent report from Allied Market Research, the global medical tourism market was worth nearly USD $61.1 billion in 2016 and the market is expected to reach a total of USD $165.3 billion by 2023, with combined annual growth rate of 15%.2

Cosmetic surgery is at the forefront of the medical tourism industry, because it is a privatized healthcare practice based on elective procedures. Cosmetic surgery patients are now able to research globally through the internet, and increasing numbers are seeking improved quality, service, and value through surgery overseas.3

Despite many reports in the press highlighting the number of patients traveling abroad for elective cosmetic surgery, little data exist in the literature about plastic surgery and medical tourism. To our knowledge, this is the largest study of its kind to examine patients traveling abroad for cosmetic surgery and the procedures they are receiving.

METHODS

We retrospectively reviewed the medical records of 658 consecutive international patients receiving cosmetic surgery at a private plastic surgery practice in Cartagena, Colombia between February 2013 and April 2018. All patients included in this study originated from outside of Colombia, underwent multidisciplinary preoperative assessment, standardized photographs, cosmetic surgery procedure(s), and follow-up care by the primary authors (C.A.C. and C.R.). Data on patient age, sex, origin, profession, procedure(s), surgical site(s), and type of anesthesia were recorded from the medical records. Professions were classified according to the International Standard Classification of Professions.4 Procedures were classified according to Current Procedure Terminology.5 A procedure was counted only once regardless of the number of sites (eg, breast lift, facelift, and liposuction). Surgical sites were recorded for individual procedures (eg, 2 breasts in a breast lift, 2 sides of a facelift, and multiple liposuction sites) and summed separately.

RESULTS

A total of 658 international patients underwent cosmetic surgery procedures by the primary authors between February 2013 and April 2018. Five hundred forty eight patients (83.3%) were female and 110 (16.7%) were male (Fig. 1). Patients ranged in age from 16 to 72 years old, with 90% of patients falling between 20 and 54 years old (Fig. 2). Patients traveled to Colombia from 34 different countries spread across 6 continents (Fig. 3). The United States was the principal source of patients (66%), with large numbers also coming from Canada (12%), the Caribbean islands (11%), and Europe (6%) (Fig. 4). Patients from the United States represented 38 states and the District of Columbia, with the largest numbers traveling from New York, Florida, New Jersey, Texas, and California (Fig. 5). Canadian patients came from 7 provinces, with the largest numbers traveling from Ontario, Alberta, British Columbia, and Montreal. A wide spectrum of occupations were represented by patients in the study, lead by professionals (25%), managers (21%), technicians and associate professionals (14%), and service and sales workers (14%) (Fig. 6).

F1
Fig. 1.:
Women accounted for 83.3% and men accounted for 16.7% of total patients.
F2
Fig. 2.:
Patients ranged in age from 16 to 72 years old, with 90% of patients falling between 20 and 54 years old.
F3
Fig. 3.:
Patients traveled to the authors’ practice in Colombia from 34 different countries spread across 6 continents.
F4
Fig. 4.:
The United States was the principal source of patients, with large numbers also coming from Canada, the Caribbean islands, and Europe.
F5
Fig. 5.:
Patients from the United States represented 38 states and the District of Columbia, with the largest numbers traveling from New York, Florida, New Jersey, Texas, and California. Canadian patients came from 7 provinces, with the largest numbers traveling from Ontario, Alberta, British Columbia, and Montreal.
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Fig. 6.:
A wide spectrum of patient occupations were represented by professionals, managers, technicians and associate professionals, and service and sales.

The 658 patients in this study had a total of 1,796 cosmetic surgery procedures, involving 5,456 surgical sites (Fig. 7). Ninety-nine percent of cases were performed under general anesthesia and 100% were performed in an accredited hospital. Patients more commonly received combination procedures (72%) versus single procedures (28%), with an average of 2.7 procedures and 8.3 surgical sites per patient (Fig. 8). The top 10 surgical procedures are listed in Figure 9. A total of 358 facial cosmetic procedures were performed (20% of total), lead by eyelid surgery, facial fat grafting, facelift/necklift, rhinoplasty, and lip augmentation. A total of 366 breast procedures were performed (20% of total) with breast lift (with or without implants), breast augmentation, gynecomastia correction, revision breast surgery, and breast reduction accounting for the majority of cases. A total of 1,071 procedures were performed on the body (60% of total) with liposuction, buttock augmentation (fat transfer), tummy tuck, arm lift, and thigh lift being the most popular. Ninety-five percent of liposuction patients had multiple areas treated (eg, abdomen, back, waist, arms, thighs, and chin) with an average of 3.8 areas treated per patient (Fig. 10). Fifty-four percent of liposuction patients had a portion of their fat transferred to the buttocks for augmentation (Brazilian butt lift).

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Fig. 7.:
The 658 patients in this study had a total of 1,796 cosmetic surgery procedures.
F8
Fig. 8.:
Ninety-nine percent of cases were performed under general anesthesia, and 100% were performed in an accredited hospital. Patients most commonly received combination procedures (72%) with an average of 2.7 procedures per patient.
F9
Fig. 9.:
Top 10 plastic surgery procedures in this study.
F10
Fig. 10.:
Ninety-five percent of liposuction patients had multiple sites treated (eg, abdomen, back, waist, arms, thighs, and neck) with an average of 3.8 sites treated per patient. Fifty-four percent of liposuction patients received fat transfer to the buttocks for augmentation (Brazilian butt lift).

Breaking down procedures by sex reveals the most popular procedures in females were liposuction, Brazilian butt lift, tummy tuck, breast lift, and breast augmentation. The most popular procedures in males were liposuction, eyelid surgery, gynecomastia correction, facelift/necklift, and facial fat grafting (Fig. 11).

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Fig. 11.:
The top 5 most popular procedures in females and males.

DISCUSSION

The cosmetic surgery industry has enjoyed substantial growth over the past 20 years. In the global marketplace, advertisements, movies, and social values increasingly promote beauty, health, and youth. Technological developments, new procedures, and a proven safety record have increasingly motivated patients to pursue aesthetic procedures. The American Society for Aesthetic Plastic Surgery (ASAPS) has documented a strong demand for plastic surgery over time, with the overall number of cosmetic procedures (surgical and nonsurgical) increasing 832% since 1997.6 In 2016, more than 13 million surgical and nonsurgical cosmetic procedures were performed in the United States with Americans spending more than USD $15 billion. Plastic surgery trends worldwide are similar, with the International Society of Aesthetic Plastic Surgery (ISAPS) reporting 23.6 million total surgical and nonsurgical procedures performed globally in 2016.7 This growth is expected to continue as people of all ages, occupations, and social classes increasingly seek cosmetic surgery.

The medical tourism industry is also growing rapidly, attracting millions of patients who seek value and excellence in healthcare services.8 It is an integrated and collaborative approach by the healthcare and tourism industries, providing patients with a unique experience combining treatment, service, and recreation. Factors that have led to the increasing popularity of medical travel include the high cost and lack of access to healthcare in home countries, ability to research providers worldwide, ease and affordability of international travel, and improvements in both technology and standards of care in many countries.9 Medical tourism represents a new segment in travel and healthcare, offering substantial savings and representing another mechanism of “value” for healthcare purchasers.10 A 2008 survey of healthcare consumers found that nearly 40% of Americans would consider having an elective procedure performed in a foreign country if they could save 50% or more and be assured that the quality was equal to or better than what they can have in the United States.11 Aggressive continued growth is expected as demand increases and advances continue to improve the end product for patients.12–14

Cosmetic surgery represents the largest segment of the medical tourism market, with 60% of medical travelers seeking aesthetic surgeries or treatments.15 Cosmetic surgery patients seek an improvement in their appearance, and pay out of pocket to achieve their goals. They desire safety, expertise, service, affordability, and an excellent overall experience.16,17

Cosmetic surgery patients are actively involved in decisions about their care and associated costs. They take initiative in improving their health, seek and use information, consider different options, and make choices that meet their preferences. They place central importance on high-quality, readily accessible, and understandable healthcare. Patients have also become increasingly savvy, and are researching options with an expectation of finding a provider that inspires confidence and tailors care to suit their personal needs. Patients are no longer limited by treatment options available in their home communities, and use the internet to research options globally. They make informed decisions based on information published by various plastic surgery societies, individual practice websites, and social media platforms such as Facebook, YouTube, Instagram, and RealSelf. Patients use the internet to contact providers directly, and plastic surgeons are increasingly making themselves available for consultations on the phone and online.

This study examines 658 consecutive patients receiving 1,796 cosmetic surgery procedures at a private plastic surgery practice in Cartagena, Colombia. Our findings are generally in parallel with patient demographic data released by the ASAPS and the ISAPS (Fig. 12).1,2 Our patient data reveal a younger demographic versus the United States, with more patients in the 19–34 age group (45% versus 25%) and less patients in the 51 and older demographic (18% versus 34%). Most popular procedures are also fairly consistent with ASAPS and ISAPS data. A notable exception is the number of patients undergoing buttock augmentation with fat grafting, which is the #2 most popular procedure in our patient cohort compared with #10 internationally and #17 in the United States. Another notable difference is that 100% of procedures performed in this study took place in an accredited hospital, compared with 47.3% internationally and 19.8% in the United States.

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Fig. 12.:
Comparison of statistics released by the ISAPS (2016), ASAPS (2016), and the authors’ practice, Premium Care Plastic Surgery.

This study is the first of its kind to examine a large of cohort plastic surgery patients traveling overseas for cosmetic procedures. We show that traveling for surgery is widely appealing, with women and men from diverse backgrounds traveling to Colombia from all over the world for a variety of procedures. We also define major trends in plastic surgery medical tourism. Eighty-three percent of patients are women and 90% are between the age of 20 and 54. Ninety percent of patients are from North America, and 72% received combination procedures with an average of 2.7 procedures per patient.

Numerous authors have expressed concern about the risks associated with patients traveling for medical procedures abroad, including the potential of receiving substandard care.17–19 We share this concern, though this is not specific to the medical tourism patient. Patient research is a key in choosing a plastic surgeon, and patients do the majority of their research online. The American Board of Plastic Surgery, the American Society of Plastic Surgery (ASPS), the ASAPS, and the ISAPS consistently emphasize the importance of board certification in plastic surgery, as this assures patients that the surgeon has achieved rigorous training, examination, and professional standing. All of the major governing bodies in plastic surgery have released guidelines for patients seeking cosmetic surgery abroad, including the ASPS, ASAPS, ISAPS, American College of Surgeons, and the American Medical Association.20–24 The ASPS has also signed formal “Global Partner” agreements with national plastic surgery societies around the world that have achieved a high standard in plastic surgery (Fig. 13), providing patients with additional assurance regarding the quality of board-certified plastic surgeons in these partner countries.25

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Fig. 13.:
The American Society of Plastic Surgeons has signed formal “Global Partner” agreements with national plastic surgery societies around the world that have achieved a high standard in plastic surgery, providing patients with additional assurance regarding the quality of board-certified plastic surgeons in these partner countries.

This study examines trends in plastic surgery medical tourism in Colombia, which has become one of the most popular destinations in the world for patients seeking surgery abroad. Known for its beautiful people and for excellence in plastic surgery, Colombia has emerged as a regional leader in the plastic surgery medical tourism industry.26,27 The ISAPS Global Statistics 2016 ranks Colombia as #9 in the world in regards to total volume of surgical procedures performed.7 Looking deeper into ISAPS Global Statistics, accounting for the population and number of plastic surgeons in the country, Colombia is #2 in the world in terms of plastic surgery procedures performed per capita (Fig. 14). The average plastic surgeon in Colombia performs 294 aesthetic procedures per year, 31% higher than average 224 surgical procedures on average performed annually by plastic surgeons in the United States. Per capita, Colombian plastic surgeons are also ranked in the top 5 in terms of procedures performed for nearly all aesthetic procedures including liposuction (#1), Brazilian butt lift (#1), breast lift (#2), posterior body lift (#2), butt implants (#2), breast augmentation (#3), tummy tuck (#3), breast reduction (#3), rhinoplasty (#4), eyelid surgery (#4), brow lift (#4), facial fat grafting (#5), arm lift (#5), thigh lift (#5), and labiaplasty (#5) (see figure, Supplemental Digital Content 1, which displays a total number of facial plastic surgery procedures performed per country and per plastic surgeon, adapted from the ISAPS International Study on Aesthetic/Cosmetic Procedures Performed in 2016, https://links.lww.com/PRSGO/B50) (see figure, Supplemental Digital Content 2, which displays a total number of breast plastic surgery procedures performed per country and per plastic surgeon, adapted from the ISAPS International Study on Aesthetic/Cosmetic Procedures Performed in 2016, https://links.lww.com/PRSGO/B51) (see figure, Supplemental Digital Content 3, which displays a total number of body plastic surgery procedures performed per country and per plastic surgeon, adapted from the ISAPS International Study on Aesthetic/Cosmetic Procedures Performed in 2016, https://links.lww.com/PRSGO/B52).

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Fig. 14.:
Analysis of ISAPS (2016) Global Statistics shows that Colombia ranks as #9 in the world in the total volume of surgical procedures performed, #2 worldwide in plastic surgery procedures performed per plastic surgeon, and #1 globally in terms of medical tourism patients treated per plastic surgeon.

Colombian plastic surgeons are also ranked #1 globally in terms of medical tourism patients, with the average plastic surgeon performing 44 surgical procedures per year on foreign patients. Aside from the skills of the surgeons themselves, Colombia possesses an established tourism industry, strong intellectual capital, and modern hospitals. The development of the health and wellness industry is a natural extension of that current infrastructure and the Colombian government has invested billions of dollars into improving the country’s medical infrastructure to provide a safe and tourist friendly environment for health travelers.28,29 The industry is government-led and private sector-driven and aims to provide the tourist to Colombia with physical invigoration, mental rejuvenation, cultural enrichment, and spiritual elevation. Costs are often 30%–40% less than in the United States and the proximity of Colombia coupled with an abundance of convenient flights make travel easier than ever.30 The growth of international patients at the authors’ practice has risen steadily over the past 5 years, providing insight into the potential for continued growth in this sector as a whole (Fig. 15).

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Fig. 15.:
The number of foreign patients receiving plastic surgery at the authors’ practice has increased steadily over the past 5 years.

The process of care is designed to add value to every part of the plastic surgery process. Patients research plastic surgery online, and our website and social media sites provide detailed information on our practice, our procedures, and our patients. After submitting medical information and photos, patients have a consultation through phone or video chat with one of our surgeons. Patient coordinators assist with scheduling and preparation for surgery including laboratory tests, medical clearances, travel, accommodation, and logistics. Our surgical packages are comprehensive and include all medical and surgical care, airport transfers, accommodation, medications, and postoperative therapy. On arrival, a driver picks up patients at the airport and a patient concierge provides a welcome introduction and settles them into their accommodation. The patient has their preoperative consultation with their plastic surgeon, and a nurse accompanies the patient to see the anesthesiologist and to gather medications, garments, and supplies for surgery. The day of the surgery a nurse picks the patient up to go to the hospital. After preoperative preparation and marking they are transported to the operating suite, which is modern with the latest anesthesia and surgical equipment. During the majority of our cases we use two plastic surgeons, allowing us to do more surgery with less anesthesia time. Operative times are kept under six hours, with a typical combination procedure taking around 4 hours.

After surgery, patients are monitored in the postanesthesia care unit until ready for discharge. Most patients are discharged the same day, though we do not hesitate to admit the patient for inpatient care when indicated. Nurses transport patients home and we provide overnight nursing on the night after surgery, and beyond if needed. Most patients recover in beach front condominiums managed by the practice, but many stay at local hotels or rented apartments. Our nursing team visits the patients every morning to provide monitoring and postoperative care, and aestheticians visit patients daily to provide therapy and massage. We stress compliance with postoperative instructions, a healthy diet, and early activity. Our intimate access to patients allows us to provide continual motivation and guidance, and to catch issues quickly when they present. When postoperative complications do arise they are treated immediately, and all patients are issued an insurance policy that covers costs related to diagnostic, hospital, and surgical fees. Patients see the plastic surgeons regularly during their postoperative course, and at the final visit we review their progression and provide instructions for care of incisions, compression of operative sites, diet recommendations, activity restrictions, and follow-up. Patients typically stay in Cartagena for seven to fourteen nights depending on the procedure(s), though this is individualized for each patient (Table 1). As recovery progresses patients are typically able to participate in light tourism activities to enjoy the city and the local culture. Occasionally trips are extended if ongoing care is recommended. We typically follow-up patients through telemedicine at 1 month, 2 months, 6 months, and 1 year after surgery, though all patients have ongoing access to their surgeons and are instructed to contact us anytime with questions or concerns.

T1
Table 1.:
Popular Cosmetic Procedures along with Typical Length of Procedure, Recommended Time in Cartagena, and Time before Returning to Work

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Supplemental Digital Content

Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.