November 15, 2011 | American Society of Registered Nurses®
Journal of Nursing

Cosmetic Surgery: Cheaper, Faster, Scarier

SAUSALITO, CA (ASRN.ORG) -- Elsie Soto says she couldn't move her legs after she had liposuction and fat-transfer surgery last year at a clinic near here. But instead of sending her to a hospital, a nurse took Soto to her own house. Soto says she has no memory of being taken to the hospital two days later — on her mother's insistence — and needed two blood transfusions when she got there.

A 32-year-old single mother, Soto said she was tired of looking at all the beautifully toned people surrounding her in this popular beach town. She went to three area plastic surgeons before deciding to have her procedures done at Strax Rejuvenation and Aesthetics Institute. It was a simple matter of cost: The other estimates ranged from $10,000 to $12,000; Strax charged $5,000.

But after almost $50,000 in medical bills (including nearly $40,000 for her hospital stay) that insurance wouldn’t cover because the procedure was elective, three months out of work and continued pain down her left leg, Soto now says low-cost, high-volume cosmetic surgery clinics are not the way to go.

Strax, which has two locations in South Florida, boasts it is the busiest cosmetic surgery center in the U.S. Soto says that's part of the problem: She thinks she was just another patient whose problems got short shrift in what seemed like an assembly line of patients.

"On Sunday morning, everyone goes to Denny's and comes in and out, in and out, in and out," says Soto, a hospital purchasing aide. "That's how it was." Soto filed a complaint against Strax with The Joint Commission, an independent, not-for-profit organization that accredits most hospitals and many health care facilities, including Strax.

Strax says it is helping consumers by making cosmetic surgery affordable for the masses. Peter Mineo, an outside attorney for Strax, said in an e-mailed statement that Soto "suffered a bruise to her sciatic nerve," which he called a rare but well-known potential complication of fat-transfer surgery to the buttocks. He says Soto was told about the risk. The nurse treating Soto was violating company policy when she took Soto to her home, Mineo says, but called it a "very kind act." And Strax believes Soto's medical problems were quickly resolved, Mineo says. 

Critics call it the commoditization of cosmetic surgery. Procedures that once included lengthy consultations with plastic surgeons and trips to the hospital, now often involve meetings in office-park surgery centers with salespeople who tell prospective patients what "work" they need and how little it can cost when performed in their offices, say former patients, other plastic surgeons and plaintiff lawyers.

While these clinics typically employ plastic surgeons who are either board-certified or up for certification, lawyers, victims and other plastic surgeons say these new-style surgery clinics are under so much sales pressure they often don't sufficiently screen patients for medical problems, do inadequate follow-up and persuade patients to undergo procedures that are either unnecessary or unlikely to get good results.

Cosmetic procedures ranging from Botox to buttocks lifts performed by plastic surgeons were up 77% last year, as consumers flock to clinics including Strax, the national chain Lifestyle Lift, and other busy cosmetic surgery centers geared to the budget-minded.

"They've created these kind of fast food courts where people go in, pick from a menu of what they want done and the physician who meets with them is not necessarily the doctor who operates on them and he's not the one who follows up with them," says Soto's lawyer here, Spencer Aronfeld, who is representing other Strax patients. "This is a recipe for disaster."

Lifestyle Lift founder David Kent says, "There are no guarantees in medicine or surgery," but that the company wants every patient to be satisfied. In a recent recruitment letter to plastic surgeons, Kent said the 39-location company, which advertises heavily on TV, plans to open 40 more clinics nationwide.

With marketers playing a key role at some cosmetic surgery centers, former patients and lawyers say some of the clinics' claims about the low risk, dramatic results and short recuperation time are misstated. Lifestyle Lift's marketing practices, which are under investigation by the Florida attorney general, are "backed up by tons and tons of research," says CEO Gordon Quick. Still, Florida's attorney general has more than 60 complaints about the company, including several contesting its claims about fast recoveries, minimal pain and results that take years off one's appearance.

Two years ago, Lifestyle Lift settled a lawsuit by then-New York attorney general Andrew Cuomo charging that the company was writing its own online testimonials for existing websites and at least 10 sites it created to appear consumer-generated.

In its settlement agreement, the attorney general's office revealed internal e-mails, including one directing a Lifestyle Lift employee to "Put your wig and skirt on and tell them about the great experience you had" on the independent site RealSelf.com. Lifestyle Lift says it was simply posting the contents of letters it received from happy patients, although the settlement agreement says evidence shows many of the postings were written entirely by employees.

Jennifer Davis, a spokeswoman for Florida Attorney General Pam Bondi, says its 16-month probe is looking at Lifestyle Lift's advertising of a "facial rejuvenation procedure that is purported by them to be safer and less expensive than other traditional procedures, totally individualized for the client, and offers a quicker recovery time." Investigators, she says, are looking into possible violations of the Florida Deceptive and Unfair Trade Practices Act, which bans commercial practices that deceive consumers.

Joyce Wooten, 53, of Tampa said her surgeries at Lifestyle Lift "ruined my life," in her complaint to the Florida attorney general. She said the healing process was longer and more difficult than she was told and heard in advertising.

"I began hiding my face everywhere I went because people stared and some gasped," Wooten wrote, citing problems including loose flaps of skin on her neck and lopsided ears.

Lifestyle Lift says it did a "revision procedure" for Wooten at no cost in late 2008, but Wooten says that was only after she threatened a lawsuit. The company says she never returned for her follow-up, which is important for healing.

Lifestyle Lift founder Kent says its centers have performed about 140,000 face-lifts and have only "a few people we could not make happy."

Barbara Schmidt, 62, of Plantation, Fla., says she is one of the happy patients. She says she was self-conscious about her chin, which looked like it was "all in one" with her neck. Her Lifestyle Lift procedure, which included liposuction to her neck, made her look so much better, strangers "smile and say hello," something that never used to happen, she says.

Aronfeld, who says he fields several calls a day from unhappy Strax patients, has formally requested arbitration — something Strax requires patients to agree in writing to do before suing — on behalf of Soto, the survivors of Lidvian Zelaya, who died in December after having liposuction and fat-transfer surgery, and Barbara Yakin, who was hospitalized after a tummy tuck, thigh lift and liposuction at Strax last September.

Four Strax patients have died in the last two years. The company says three out of the four deaths were unrelated to complications of their surgeries. Zelaya, according to her autopsy, died of an "embolism due to complications of liposuction and fat transfer surgery." In a statement, Mineo called the embolism an "unavoidable complication of liposuction."

Miami plastic surgeon Alberto Gallerani wrote in an affidavit for the case that the amount of fat transferred and the fact it wasn't done in a hospital unnecessarily increased the risk of a fatal embolism. Roger Gordon, the doctor who performed the surgery, no longer has hospital privileges, according to the Northshore Medical Center FMC Campus and Florida Board of Medicine records.

Another patient died of an overdose of pain medication, the autopsy shows, and Mineo says it was far more than Strax prescribed. The autopsy shows another died of blood poisoning from a wound infection — for which the patient "didn't seek timely medical attention," Mineo says. The fourth died of an "underlying and very rare" disease — Uhl's — that can only be detected through genetic testing or an autopsy, Mineo says.

Mineo maintains that Strax's safety record is "second to none." He says Zelaya is Strax's "one fatal complication" in the universe of 90,000 procedures it has performed. The cosmetic surgery field has a generally accepted level of mortality of one for every 50,000 surgeries, according to widely cited reports. That would give Strax a mortality rate that's about half the accepted level, Mineo says.

But Strax actually has a rate of four deaths in 90,000, which makes Strax's mortality rate almost twice what's considered acceptable in cosmetic surgery, says Miami plastic surgeon Adam Rubinstein. The American Association for Accreditation of Ambulatory Surgery Facilities, which accredits most outpatient surgery centers, mandates in their standards that all deaths occurring within 30 days after a surgery are included in their mortality rates, according to experts including Beverly Hills plastic surgeon Geoffrey Keyes, AAAASF's president-elect. Keyes is the lead author of two peer-reviewed studies of safety and fatalities in outpatient surgery, including one that analyzed more than 6 million procedures and found a death rate of one in 50,000 procedures.

Yakin, 60, says she collapsed when she got home after her Strax procedures, spent two days in intensive care at the hospital and required three more surgeries to correct infected wounds on her thighs and stomach.

"The pain and suffering I went through, no one should have to go through," Yakin says.

Yakin developed a hematoma after the surgery, says Mineo, who called it a "well-recognized complication." Yakin was taking blood thinner medication so was cleared by her medical doctor — though not a cardiologist — before the surgery and stopped taking the medicine, Mineo says.

Yakin's doctor, Jeffrey Hamm, was on probation until last September following disciplinary action by Florida's Board of Medicine.

In its complaint, the board charged that Hamm — while working for Strax — failed to meet the "standard of care" for a patient after he didn't order additional lab tests or consultations when tests showed the person had "dangerously elevated" blood glucose levels. This earlier patient was hospitalized for almost two months with septic shock, respiratory and renal failure. Mineo says Hamm settled those charges because he "was financially broken by the proceedings."

In May 2009, Aura Javellana, 28, of Redmond, Wash., died of "acute lidocaine intoxication," according to the autopsy report. The day before, she had a liposuction procedure at Sono Bello Body Contouring Center, which has 10 locations in seven states. She took a cab by herself from Sono Bello to a hotel room to recuperate and was found dead by maids the next morning.

A lawsuit against Sono Bello filed by attorney Cydney Campbell Webster on behalf of the Javellana family alleged Javellana was not evaluated by any "licensed medical professional" — only a company consultant — and didn't meet her doctor until right before the surgery. 

The lawsuit also charged that the company falsely promoted the procedure as safe, saying it "ruled out" the complications from traditional liposuction.

The Washington state health department charged that the doctor who performed the surgery, Marco Sobrino, was guilty of unprofessional conduct, which means it believes his conduct met the legal definition of "incompetence, negligence or malpractice," says spokesman Gordon MacCracken. A hearing that could result in Sobrino having his license revoked is set for Sept. 27.

Penn Gheen, an attorney representing Sono Bello, says a marketing person who was "let go" created some materials independently that were given to some patients and "probably did downplay the risks more than the official materials." In a response to the suit, Sobrino's attorney denied that he was guilty of wrongful death or medical negligence.

The case was settled out of court in July for about $1.9 million, according to settlement documents filed in the case.

Phil Haeck, a Seattle plastic surgeon who heads the American Society of Plastic Surgeons, says the new approach to cosmetic surgery is especially worrisome when "medical professionals are not making the decisions."

"It violates the old doctor-patient relationship," Haeck says. "People want it cheaper, faster and don't ask enough questions."

Along with the Florida complaints, Lifestyle Lift has a 51% "worth it" rating among 360 reviews on RealSelf.com, a website about cosmetic procedures. The Better Business Bureau has received 19 complaints about the company in the past three years, nearly all about "products or services." Of those, 15 complaints were resolved with the assistance of BBB and four couldn't be resolved to the customer's satisfaction.

While these centers typically employ board-certified plastic surgeons, some don't have privileges to treat patients at hospitals, leaving patients to fend for themselves at emergency rooms. Soto says she now wishes she had her procedure performed at a hospital rather than an outpatient surgical center "so that if anything happened I was already there."

Doing procedures in office surgery centers saves money, something that many consumers, including Wooten, say they found attractive — at least until they realized that it can be traumatic to have surgery under the local anesthesia often used in office settings.

Lifestyle Lift uses only oral sedatives and injections of a painkiller, lidocaine, which is similar to novocaine. Its offices are not accredited by any of the groups that certify hospitals or surgical centers, which rules out even the use of intravenous sedation to put patients into what's known as a partially asleep "twilight" state.

Kent says the centers have all the emergency equipment accreditation companies would require.

Wooten says that during her Lifestyle Lift procedure, she could tell the doctor was cutting around her ear and hitting it to get it to come loose from her head, according to her complaint to the Florida attorney general.

"I wish I had been completely asleep," Wooten said. "The worst part is remembering."

Kent acknowledges that local anesthesia is not for everyone and says the downsides are fully explained to patients.

And some satisfied former Lifestyle Lift patients, whose names were provided by the company, say they wouldn't have it any other way. Beatriz Newnam, 52, of Marco, Fla., says she was laughing and "telling jokes" during her surgery last August, which included an eyelift, face-lift, neck liposuction and lip augmentation.

Orlando facial plastic surgeon Edward Gross filed a complaint with the Florida Board of Medicine after he provided emergency room services in 2008 for what he called the "life threatening" condition of a Lifestyle Lift patient.

In the complaint, Gross wrote that the patient was "bleeding from the face" and needed emergency assistance with breathing and surgery for hematomas. He wrote that the patient, who settled a lawsuit against Lifestyle Lift out of court, was in intensive care on a ventilator and breathing tubes for six days.

He also charged that patient safety was at risk because her doctor didn't have hospital privileges and the facility did not meet the state's "standard of care" for office surgery.

Lifestyle Lift denied all allegations related to the safety of its facility and doctor, according to its response to a lawsuit Gross filed against the company seeking payment for these services.

Michelle Cordi of Orlando sued Lifestyle Lift last year, charging that she didn't get medical care from the company before her surgery and that the procedure left her with a wound that wasn't treated properly, which led to her hospitalization.

In a response to the suit, Lifestyle Lift denied the allegations and said it was not negligent.

"We've learned that the way you treat patients is as important as the medical procedure itself in terms of satisfaction," Quick says. "It's something the company continues to get better and better at."

Malcolm Paul, a prominent Newport Beach, Calif., plastic surgeon, says that after he saw a Lifestyle Lift plastic surgeon perform a face-lift, he became so convinced of the approach that he is now working as a consultant to the company.

In the recent letter sent to plastic surgeons Kent said top-performing doctors earn more than $1 million a year in net income and those working two days a week can earn $450,000 a year.

Stephen Prendiville, a Fort Meyers, Fla., facial plastic surgeon, says he's treated several patients who were unhappy with the results they got at Lifestyle Lift. Most had "visible, poorly executed face-lift scars with no discernible aesthetic improvement," he says. 

Prendiville says Lifestyle Lift's claims aren't based on any studies ever published in surgical journals, and the company uses terms including "revolutionary" when, he says, their procedure is really just a variant of a quick face-lift that's been done for decades by others.

Kent says the company now does small, medium and large-incision face-lifts and that the larger incisions are for people who have more sagging. Quick says traditional face-lifts are "a more invasive process" as they "go farther under the skin."

As for Soto, she says she still often cries herself to sleep because of the pain since her surgery. And she's changed her view on the competition to look good around her hometown.

"This is who I am. I'm not going to try to change," says Soto. "I'm just thankful I'm alive."



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>Nation's "Epicenter" Crackdown On Prescription Drug Abuse

>Changes Sought To Save Key Aspect Of Healthcare Law

>Hospitals To Lose Funds, Jobs, If Medicaid Cut

>Couples Pull Back From Edge Of Divorce

>Cosmetic Surgery: Cheaper, Faster, Scarier

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