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VOL. 40 | NO. 9 | Friday, February 26, 2016

Doctors: 'Buyer beware' as cosmetic surgery grows

By Jeannie Naujeck

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If you often look around and feel older than you used to, it might not be you. It might be that everyone else looks younger.

The face of Tennessee is changing – literally – and as an influx of new residents and a booming economy creates a larger affluent class with more disposable income, the business of cosmetic procedures is on the rise.

Plastic surgeons report business returning to pre-recession levels, and “medical spas” are popping up everywhere, promising everyone a more youthful appearance through the wonders of peels, injectables, lasers and fat-burning treatments that can be administered on a lunch break.

“We are a bellwether of what the economy’s doing. You can definitely tell Nashville’s growing by the number of people coming in and where they’re coming from,” says Don Griffin, M.D., a board-certified plastic surgeon and owner of Nashville Cosmetic Surgery in Belle Meade.

Business is so good, especially in the Midstate, that doctors from other specialties are switching in order to cash in on the appetite for cosmetic procedures. And nurses and aestheticians are opening up skin treatment centers and administering injectables and fillers – even in people’s homes.

But many longtime surgeons warn the demand for services, coupled with a lack of regulation, has created a “wild west” scenario in the state where some “medi-spas” are opening up without adequate medical supervision.

New patients are coming in with botched procedures that need to be fixed, or tales of spending money on a treatment that promised results but did nothing.

“There are a lot of shysters; there’s a lot of snake oil in this industry,” explains Steven Bengelsdorf, M.D., owner of Franklin Skin & Laser and a board-certified surgeon who is pushing for more regulation of medical spas.

“Many sites that use the term medical have absolutely no physician supervision whatsoever. It’s very much buyer beware.”

Clint Kelly, a medical malpractice attorney based in Hendersonville, says the lines of demarcation between specialties are being blurred, partly due to the fact that anyone with a medical degree can technically perform surgery – no matter what their specialty is.

“You’re seeing dentists, osteopaths, dermatologists, ear, nose and throat doctors moving into these areas that were traditionally occupied by plastic surgeons because there is so much money to be made,” Kelly adds.

“You can’t regulate plastic surgery. But you can regulate these people that are performing laser surgeries and who can perform them.

“I think you’re going to see more and more people complaining or filing lawsuits for injuries caused by physician assistants, nurses, medical assistants performing procedures that probably shouldn’t be doing it. It’s fairly unregulated. It’s kind of the wild, wild west of medicine right now.”

Legislature and med spa industry

A medical spa is any entity that offers or performs cosmetic medical services, defined as “any service that uses biologic or synthetic material, a chemical application, a mechanical device, or a displaced energy form of any kind that alters or damages, or is capable of altering or damaging, living tissue to improve the patient’s appearance or achieve an aesthetic result,” according to the state Board of Medical Examiners.

(In contrast, barbers, nail technicians and traditional skin care practitioners work on what is considered “dead tissue.”)

Until this year, there was little regulation of the medical spa industry.

The state did enact a law that took effect January 1 requiring owners of all medical spas to register with the Board of Medical Examiners, including the name of the supervising physician.

As of February 3, the list contains nearly 300 “medical spas” – a term that includes board-certified surgeon’s offices, salons and skin care centers.

It’s a small step toward further regulation, but the registry has a number of loopholes.

For example, while supervising physicians must have an active medical license and practice, they do not have to be involved in the daily operations of the spa or even live on the same side of the state, meaning they may not be available to patients if complications arise.

They can also sign off on medical equipment such as lasers for the practice without knowing how to use them.

Supervising physicians are also not required to have experience in any relevant specialty, meaning a psychiatrist could, theoretically, act as a supervising physician.

One medical spa lists a supervising physician whose career experience is in public health.

“In some situations where entrepreneurs are paying physicians to use their medical licenses, they don’t require them to come in and take care of complications. Clearly, if that supervising physician is in another part of the state that’s not going to happen,” Bengelsdorf points out.

The state does have stringent regulations regarding office-based surgery. In Tennessee, surgery levels are based on the amount of sedation or anesthesia required.

Level 1 office surgery, the lowest level, refers to minor procedures in which no or minimal anesthesia is involved and the chances of complication requiring hospitalization are low. Examples include mole excision, biopsies and liposuction involving minor amounts of fat.

Level 2 and 2A procedures require greater sedation and include hernia repairs, colonoscopies and endoscopic procedures. Level 3 procedures require deep sedation, including general anesthesia, for major procedures and require office surgical suites to adhere to hospital-like standards of care and safety.

Many cosmetic surgery procedures don’t require general anesthesia and can be done in an office.

For example, NuBody Concepts of Brentwood and Memphis offers services like tummy tucks and breast augmentation. Patients there go under “twilight” sedation, a combination of IV sedation and local anesthesia, which results in shorter recovery time.

“The state is beginning to tighten up their med spa rules and will continue to,” says Joe DeLozier, M.D., a well-known plastic surgeon in Nashville who operates DeLozier Cosmetic Surgery Center and is medical director for Elan, a well-established hair and skin salon and clinic that offers Botox, Coolsculpting [fat freezing], hair transplants and more.

DeLozier adds Tennessee generally follows the lead of states like Florida and California, which are at the forefront of medical regulation.

“We play by the rules, but there are some places that don’t. As the rules are tightened, it will be to the public’s benefit.”

Complications can results in death

Though complications from cosmetic procedures are relatively rare, there have been recent deaths in Tennessee.

Attorney Kelly has represented the plaintiffs in two cases in Nashville where a cosmetic procedure resulted in death.

One 43-year-old woman died after a liposuction in which a board-certified plastic surgeon perforated her small intestine in three places.

After complaining of severe pain for several days, she was sent home with pain medication and later died of complications from peritonitis – an infection caused by bowel material leaking into the stomach.

In another case, a 30-year-old woman died after a general surgeon who was not specially trained in cosmetic procedures nicked her bowel during surgery to remove excess skin.

Both cases were settled confidentially out of court, and the surgeon in the second case went out of business the next year.

However, the plastic surgeon in the first case stayed in business, and Kelly has since learned that he is being implicated in the death of another patient in the same manner.

“There are situations where physicians make mistakes. I don’t want to destroy a doctor for one mistake,” Kelly explains.

“That’s why he has insurance and that’s why we have a civil justice system – to address those wrongs and for people to be made whole when that happens. Then when I found out he did it again, that’s when I realized this guy’s got to get out of business.”

In both of Kelly’s cases, the patient didn’t die during surgery. She died from lack of appropriate follow-up care after a complication.

“A lot of times it’s not the procedure itself that kills the patient. It’s the complications,” Kelly adds.

“There’s a dangerous condition inside the patient’s body that leads to death, and it happens when doctors ignore the patient’s complaints, signs and symptoms of impending doom.

“You want somebody who can recognize complications early and deal with them quickly. That’s for surgery across the board.”

Kelly is currently representing a client who lost a nipple and areola to gangrene after a physician mixed her up with another patient and performed the wrong breast procedure.

Most people who are injured by a cosmetic procedure have no recourse because most injuries are not bad enough to warrant a lawsuit. They also have little protection against consumer fraud for a procedure that either doesn’t improve their appearance or, worse, makes them look bad or lose function.

“I don’t know how many times people come to me and they had bad work done somewhere else,” says Jay Lucas, M.D., owner of Lucas Center Plastic Surgery in Knoxville.

“They had it done on the cheap and they had a disastrous result, they are out of money, and they come to me and it’s going to cost them more.

“If they would have just done their homework – look at people’s credentials, make sure they are truly board-certified – they would be in much better shape.”

Licensure versus certification

The best way to protect oneself is to check the credentials of whomever will be performing a medical procedure. To practice medicine in the United States, doctors must be licensed by the medical board of the state in which they work. However, that does not guarantee a physician is experienced in a certain specialty, as any physician with a medical license is technically allowed to perform plastic surgery.

Consumers can look up any Tennessee-licensed doctor at the Tennessee Board of Medical Examiners website (www.tn.gov/health/topic/ME-board) and find out the status of their license, what training he or she has received, board certifications and any disciplinary actions and criminal offenses.

In addition to licensure, the site also has a link to the new medical spa registry.

People considering a cosmetic procedure can also see if the professional is board-certified in a specialty by checking the American Board of Medical Specialties website, www.abms.org. Board certification is a voluntary credential that indicates a physician has undergone a standard of training in a specialty.

There are certifying boards for 24 medical specialties such as surgery, plastic surgery, dermatology and anesthesiology.

While the term “cosmetic surgery” is often used interchangeably with “plastic surgery,” they are not the same.

Plastic surgery is a defined medical specialty, and comes from the Greek word plastikos, which means “able to be molded.” Plastic surgeons are often called in to reconstruct and restore to function parts of the body that have been damaged by trauma, such as a hand crushed and shattered in a car accident.

“What patients need to know is an ABMS board-certified physician is much different from a non-ABMS board certified physician,” says Griffin.

“Cosmetic surgery is a facet of plastic surgery, but people who are not plastic surgeons do it too. There isn’t any official ABMS-designated specialty in cosmetic surgery.”

Kelly foresees even more competition as entrepreneurs take advantage of the growing market for “ageless” medicine and treatment.

“Nashville’s population is increasing, and the kind of people that are coming into this city have money,” he adds.

That may not soothe those who are concerned about public welfare.

“I went to medical school knowing I wanted to be a plastic surgeon because I think like an artist and an engineer, and that is what a plastic surgeon is,” Lucas says.

“We are innovators and we are artists. And if you don’t have that three-dimensional thinking – the perspective of balance and all that other stuff – you can’t do it.

“The problem is, medicine has changed. The reimbursements are not as good, and people are trying to find some pot of gold somewhere. They think, ‘I can be a plastic surgeon,’ but they don’t have the skill set, and they really can hurt people.”

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