10 things plastic surgeons won’t tell you.

What to know before you and your wallet go under the knife

By Elizabeth O'Brien and Jim Rendon

1. “I trained a whole weekend to learn this procedure.”
Dentists, gynecologists, barely trained spa technicians — it seems like everyone’s offering anti-aging treatments these days.

 And no wonder: Cosmetic treatments are a lucrative business, with $11 billion spent (on 14.6 million procedures) in the U.S. in 2012, up 5.5% from 2011, according to the American Society of Plastic Surgeons.

That’s appealing not only to physicians hoping to offset the costs of higher malpractice premiums and lower reimbursements from insurance carriers but also to so-called medical spas that don’t even have a doctor on site when certain treatments are administered.

Traditionally, doctors from just four medical specialties — plastic surgery, dermatology, otolaryngology (ear, nose and throat), and ophthalmology — have handled the bulk of cosmetic offerings, including everything from minimally invasive aesthetic treatments like botulinum toxin (sold under the brand name Botox) to more involved procedures like face-lifts. And those specialists spend years honing their chops in residency training programs that teach skills unique to each specialty in addition to basic surgical skills.

Five things plastic surgeons won't tell you

Americans spend billions on cosmetic plastic surgery every year but MarketWatch's Thomas Bemis says there are things you may want to know before you and your wallet go under the knife. (Photo: Getty Images)

By contrast, those hoping to offer a little Botox in between filling cavities or giving Pap smears tend to opt for quicker training in cosmetic procedures, including weekend workshops offered by the International Society of Cosmetogynecology, an organization that promotes plastic surgery as an extension of gynecology, two specialties that are linked mainly by their female patient base. (Dr. Marco A. Pelosi III, a cosmetic gynecologist and founder of the association, says that the relevant skills and knowledge necessary to grasp and master the majority of common aesthetic contouring is easily understood and quickly learned, as the requisite skills are common to all surgery.)

Indeed, less formal training doesn’t necessarily correlate to reduced proficiency. Experts urge consumers to look for physicians with extensive experience, which could potentially compensate for shorter training. Still, some experts worry that it’s difficult for consumers to distinguish between hype and quality: “Unfortunately, this is an industry where the most creative, assertive, sexiest marketing often drives the business, but it may not be someone with the best experience,” said David B. Sarwer, a professor of psychology at the Perelman School of Medicine at the University of Pennsylvania.

2. “Discomfort? More like extreme pain and oozing.”

Before Kim Gregson, 49, had her tummy tuck and liposuction operation several years ago, her doctor told her she’d experience some “discomfort” after the surgery. The reality was some of the most intense pain she’d ever experienced, says Gregson, a human resources professional in Madison, Wis.

While she couldn’t be happier with her results three years later, she still shudders at the memory of the recovery: Despite regular doses of two prescription painkillers and ibuprofen, “I was miserable,” she says.

Blood oozed from the two temporary drainage pipes that hung from her hipbone-to-hipbone incision. After the worst of the pain subsided, the swelling began. Her doctor’s office said it would be “mild.” Instead, she had massive swelling that lasted for seven months. Forget about skinny jeans — she didn’t fit into her regular, pre-surgery pants for more than two months after surgery.

Gregson had requested two weeks off work but ended up taking three and a half, returning swollen and sore nonetheless.

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There’s a general perception in society that cosmetic surgery is somehow less physically taxing than regular surgery, since it’s elective and aesthetic in nature, says Dr. Robert X. Murphy Jr., president of the American Society of Plastic Surgeons and a practicing plastic surgeon at the Lehigh Valley Health Network in Bethlehem, Pa.

Surgeons should stress during the pre-operative discussions that “this is a real operation, not something whimsical,” he says. He uses diagrams to reinforce that message, showing how much of the body is affected by different procedures. (Some patients might be surprised that work during a tummy tuck extends from the rib cage all the way down to the pubic bone, for example.)

Dr. Jack Fisher, president of the American Society for Aesthetic Plastic Surgery and a practicing plastic surgeon in Nashville, says there’s a “continuum of recovery” with plastic surgery procedures, and some patients fall on one end or the other.

Tummy tucks cause some of the worst discomfort of any procedure, he says, since they tend to involve a long incision and extensive muscle repair and tightening; what’s more, of all tummy tucks, those done after extreme weight loss on excess skin (as opposed to on postpartum pooches) tend to be the most intensive, Fisher says. Gregson had her surgery to trim excess skin after losing 60 pounds on her own beforehand.

3. “Bargains can come back to bite you.”

With social media sites handing out cosmetic-treatment discounts like candy, it’s easy to get caught up in bargain-hunting for Botox. But cosmetic procedures — from facial fillers to face-lifts — are not commodities that are equivalent regardless of the practitioner, some doctors caution. “No two surgeons have the same pair of hands, experience and knowledge,” says Dr. Foad Nahai, editor-in-chief of the Aesthetic Surgery Journal, a publication of the American Society for Aesthetic Plastic Surgery, and a plastic surgeon in Atlanta.

Complications from botched procedures can range from the cosmetic (think: frozen facial muscles) to the fatal, as in cases where patients have died from infections and other post-surgery complications.
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Patients should also be cautious about going abroad for treatments, some experts say. While a tummy tuck in a developing country might set you back $3,000, half of what it costs here, that savings can be easily swallowed up if complications occur. Dr. Eric Swanson, a plastic surgeon in Kansas City, Kan., says he treats patients who’ve had less-than-optimal surgeries abroad. In the case of a tummy tuck, he may have to fix the belly button scar or even redo the entire surgery.

There are plenty of skilled surgeons abroad, says Swanson, who spent part of his training in Mexico City, but in some places doctors’ skill levels vary more than here, and regulations can also be more lax. “It’s not like taking a cheap cruise, where you’re not taking a chance with your life,” Swanson says.

4. “Long-term effects? Beats me.”

More than other specialists, plastic surgeons are under pressure to compete with one another, and an easy way to get the upper hand is to offer all the latest technology. Doctors are sometimes happy to try new techniques before the long-term effects are clear. While still a small part of the overall market, cosmetic vaginal “rejuvenation” surgery is popular in certain circles despite concern by the American College of Obstetricians and Gynecologists and others about the long-term safety and questionable ethics of the procedure.

Even when a procedure isn’t new or controversial, there’s hardly a wealth of information on long-term results. While a prospective patient has only to do an online search of a procedure to come up with half-naked pictures and commentary from patients who have had it done at websites such as RealSelf.com, an online community, most of the talk surrounds the procedure and its immediate results. Fewer patients weigh in decades after the fact. And in their “after” shots, surgeons don’t often include photos of a procedure years later.

“They’ll all say their techniques will give you the longest result,” says Nicole Fallen, 38, a mother of three (including twins carried to term) from the San Francisco Bay Area. She says she interviewed at least seven surgeons before choosing one — based in part on his communication skills — to perform a tummy tuck and breast lift that also corrected her pregnancy-related diastasis recti (a separation of the abdominal muscles).

5. “I make a mint off other surgeons’ mistakes.”

Dr. Sam Rizk, a plastic surgeon in New York City, says 1 out of 3 of his rhinoplasty patients have had previous nose jobs. Among the most common problems he sees are “scooped bridges,” over-restricted nostrils, and pinched tips.

The number of botched nose jobs he has repaired has soared over the past three to five years as more surgeons are performing the surgery who aren’t well trained or experienced, he says. Industrywide statistics bear out his experience: Revision surgery is up 35% from 2008 to 2012, according to the American Academy of Facial Plastic and Reconstructive Surgery.

What’s more, “revision rhinoplasty” is a more complex procedure that can take twice or three times as long as the original surgery — and can cost 50% to 100% more, depending on what’s needed. Dr. David McDaniel, a dermatologist in Virginia Beach, Va., says he spends much more time these days correcting others’ mistakes with lasers and injectables than he did even a few years ago.

6. “You look great; your husband needs some work.”

Swanson says men usually come to him for a face-lift around age 65, whereas women come in a good 10 years earlier, at age 55.

“There’s a difference in tolerance for wrinkles in our society,” Swanson says.

Men are told that they look distinguished with crow’s feet, while women hear that they look just plain old.

The tipping point for men, Swanson says, is their desire to get rid of the “turkey wattle.”

Click to Play

Boomer men take the Botox plunge

However stealthily, men are having a little work done in increasing numbers these days. Elizabeth O'Brien and dermatologist Dr. David McDaniel explain on Lunch Break. Photo: Shutterstock.
While men represent just 9% of cosmetic procedure patients, they’re increasingly getting a little work done these days, according to the American Society of Plastic Surgeons.

Total cosmetic procedures for men rose 22% from 2000 through 2012, according to the society. Minimally invasive procedures in particular have soared, with botulinum toxin treatments up 314% during that time. Some men are getting injections to look younger on the job, while others are getting treatments to keep up with their younger girlfriends, plastic surgeons and dermatologist report.

 7. “Sure, I can turn back the clock, but it just starts again.”

Just because you shelled out $10,000 for a face-lift doesn’t mean you’re set for life. Even the most skillful work will need some attention a decade or so down the line. Some jobs may require supplemental fillers (compounds that are injected under wrinkle lines into the skin) or minor surgery to tighten up a few sags, while others could call for a repeat of the same procedure. A face-lift can be expected to last about eight to 10 years, says Nahai, the Atlanta surgeon and editor.

Exact results will depend on the condition of the patient’s skin; how well the patient cares for the skin, such as by keeping out of the sun and maintaining a stable, healthy weight; and the surgeon’s skill. Any work done on the lower face will age more quickly than on the upper face since the lower is fleshier and has less bone for sagging skin to hang onto: “The jowls are the first to come back,” Nahai says.

8. “You’d be better off spending money on a good therapist.”

Cosmetic surgery doesn’t make you crazy, but research suggests those who have had it, both men and women, are more likely to suffer from psychological problems. Several studies in the 2000s found that women who chose to get breast implants were two to three times more likely to commit suicide than demographically similar women without cosmetic implants. And 20% of patients seeking cosmetic treatments were on some kind of psychiatric medication (versus roughly 9% of the overall population, according to the Centers for Disease Control and Prevention), including drugs to treat depression or a low-grade mood disorder, according to a 2004 study by researchers at the Center for Human Appearance at the University of Pennsylvania’s Perelman School of Medicine.

In addition, up to 15% of cosmetic plastic surgery patients suffer from “body dysmorphic disorder,” versus an estimated 1% to 2% of the of the overall population, according to UPenn’s Sarwer; the disorder is marked by obsessive and exaggerated concern over aspects of one’s appearance. It may sound like a convenient diagnosis for our beauty-obsessed culture, but it is a very real, very dangerous condition.

“At the extreme, people will not leave their home, they’re so preoccupied with how they look,” Sarwer says. BDD suffers often seek plastic surgery thinking it will magically transform their lives, and when it doesn’t, they may harm themselves — or sue the surgeon, Sarwer says. Every plastic surgeon worth his or her salt asks questions to gauge patients’ motives, and concerned doctors should refer patients to a mental health professional. But to date there’s no standardized screening tool for BDD.

9. “Of course I’m board certified, for what it’s worth.”

A board-certified plastic surgeon should be the best, right? Not always. Because any medical doctor can legally perform any cosmetic procedure, without obtaining any specific certification, and because certification boards are self-regulating, many certifications aren’t so telling.

The American Board of Laser Surgery, for example, certifies nurses, veterinarians and oral surgeons in laser surgery — through a take-home written exam and video Web conference. “This being the U.S. and the land of entrepreneurship, just saying you’re board certified is not enough,” says Nahai. “Ask them which board.”

There are some certifications that matter. The American Board of Plastic Surgery’s is one of the most rigorous for this specialty and the only certification for whole-body plastic surgery recognized by the American Board of Medical Specialties that provides training and assessment for entire body cosmetic, plastic surgery, and reconstructive treatments.

The American Board of Medical Specialties is a nonprofit organization that’s widely recognized as a leader in physician certification. Members of the ABPS have completed residences in both general surgery and plastic surgery and are trained to do all procedures from liposuction to nose jobs.

Other ABMS Member Boards may have some specific plastic surgery procedures for which their certified physicians are also qualified (for example, physician members of the American Board of Otolaryngology may be very well qualified to perform nose jobs). The American Board of Medical Specialties runs a website, CertificationMatters.org, where patients can see if their doctor is certified by a rigorous board.

10. “Those who need surgery the most will benefit from it the least.”

Most people turn to plastic surgery when they feel age has finally caught up with them and nothing else will rid them of that troublesome bulge or crease. But the dirty little secret of plastic surgery is that with many procedures, the more you need it, the less of an impact you can expect.

Those who have damaged skin, more common as we age, can expect some serious complications. Skin stretched by weight gain, for example, loses its elasticity; following liposuction, skin may not snap back into place but instead will hang like an apron over the area that was suctioned.

Because smokers have poor circulation to the epidermis, their skin can die after surgery, meaning months of unsightly scars and possible additional surgery. And procedures such as a face-lift done on sun-damaged skin won’t last as long and may result in more-prominent scarring. Likewise, those hoping for dramatic weight loss from liposuction are looking in the wrong place; surgeons say it’s meant only to shape a certain part of the body in conjunction with diet and exercise.

Ironically, those who need cosmetic treatments the least — generally, those who are younger (say, in their late 30s or 40s) and opt for a little tweaking here and there — are going to fare the best. What’s more, while plastic surgeons sometimes downplay the role that lifestyle can play in one’s looks, a growing body of evidence suggests that overall health and appearance are indeed related, Sarwer said.

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