Cosmetic Surgery Concerns Amplified

Plastic surgery is medicine’s final frontier: The only specialty in which doctors operate virtually free from the rules and monetary restrictions often imposed by managed care, since the procedures are almost always considered elective and are rarely covered by health plans.

Such freedom, some plastic surgeons say, has made the field a magnet for doctors seeking to avoid financial oversight of health maintenance organizations, and has created a dangerous and occasionally deadly mix of money and medicine.

The warnings from plastic surgeons of troubles within their ranks have been growing for years. But the death in March of a La Habra woman after more than 10 hours of liposuction and plastic surgery has turned what had been muffled self-criticism into highly public soul-searching.

“For better or for worse, plastic surgery is the only field free of the alphabet soup pouring down from Washington--HMOs, PPIs and such,” said Mark Gorney, medical director of the Doctors Insurance Co., the state’s largest carrier of malpractice insurance.

“So consequently a great number of physicians whose incomes are really squeezed are going into the field,” said Gorney, who is also past president of the California Society of Plastic Surgery.

Anyone with a medical degree can legally perform cosmetic surgery in California. No special training is required.

Doctors also can become board certified in cosmetic surgery, which requires a higher level of training. The American Board of Plastic Surgery requires two years of training in plastic surgery and two years of practice as a plastic surgeon, in addition to passing grades on its examinations.

But anyone with a medical degree can simply hang a shingle, run an ad, and begin performing liposuction with little more than a weekend course on how to do it, doctors and officials said.

“I’m on a crusade right now, not to destroy the field of plastic surgery or make patients worry, but to show how serious this problem really is,” said Newport Beach plastic surgeon Frederick Grazer. “This has been coming on for a long time now.”

While almost any physician can perform liposuction, Grazer said, other skills are needed to ensure patients’ safety.

“You can teach an orangutan to put the [tube] in and move it back and forth, but it’s the judgment in treating the patient and understanding the medications that’s the main thing,” Grazer said.

Primarily because of the way most managed care plans are written, elective plastic surgery is not covered by insurance. Generally, patients pay up front for such procedures, or finance them.

“All of this comes to money,” Grazer said. “Money, money, money.”

Until recently, elective plastic surgery in Orange County has been a mix of medicine, wealth and the yearning for beauty.

Now, add fear to the formula.

Judy Fernandez, 47, the La Habra woman, bled to death after Dr. William Earle Matory withdrew about 20 pounds of fat from her body during surgery in March.

Several doctors have said Matory removed too much fat at one time. But they also said that criticism of the lengthy procedure is misguided and that 10 hours of surgery is not necessarily too long.

Fernandez had done her homework before choosing a doctor. Matory, whose license has since been temporarily suspended by an Orange County Superior Court commissioner, had a good resume and experience, and he had done work on her mother.

The license of the anesthesiologist who worked on Fernandez, Dr. Robert Ken Hoo, also has been suspended.

The incident has caused other patients to begin asking more questions, and delay or cancel surgery, some physicians said.

“I was at a meeting [of plastic surgeons] the other night and when this came out everyone there said this has had a wide-reaching effect--some said their liposuction patients had canceled,” said Dr. Robert Miner, past president of the Orange County Assn. of Plastic Surgeons.

“Several of my patients have asked me about it--they wonder why such a thing happened.”

But Miner said he has frequently witnessed the botched jobs of inept plastic surgeons.

“I’ve had to put skin grafts on eyelids of people who had them done by people who had no surgical training [in that area],” Miner said.

“We now have people who give seminars on breast surgery who aren’t trained in it; we have people who give seminars on cosmetic surgery who went for a weekend course. We have people who watched someone else use a laser and then went home to start to using it on patients,” Miner said.

“It’s the same with [facial] peels--everyone and their Aunt Matilda is doing it,” he said.

However appealing the idea of buying a short cut to a great body, doctors emphasize that liposuction is not a weight reduction tool and using it as such can lead to danger.

Liposuction was designed for fit women and men who have little areas on their bodies that dieting and exercise can’t remove.

New developments allow more fat to be removed by liposuction, but it still remains a body contouring, not reshaping procedure.

“Nobody but nobody can deliver the quality of results you see in advertisements--those before and after pictures you see often have been computerized,” Grazer said.

Patients must conduct thorough interviews with surgeons, Grazer said, inquiring not only when and where they went to medical school, but whether they have hospital privileges, among other questions.

Dr. James Wells of Newport Beach agreed that patients must conduct extensive interviews with their surgeons.

“Patients must do their homework,” Wells said. “If you have a ruptured appendix you need to have it out. If you have some wrinkles, it’s not urgent that they be removed.”

Even under the best circumstances, surgery is not always successful, Wells said.

“Good doctors get in trouble--it’s the nature of medicine,” he said. “Nobody’s perfect and we’re not saints. Things will happen.”

While Grazer and several other plastic surgeons balked at the idea of more government regulation of the field, there are calls for more controls nonetheless.

Miner suggested requiring some type of specialty licensing process.

Medical ethicist Arthur Caplan believes that closer regulation of the field would benefit both patients and doctors.

“I think it’s fair to say the overwhelming majority of plastic surgeons are ethical people--but in spite of that, we do need more regulation,” said Caplan, the director of the Center of Bioethics at the University of Pennsylvania.

“But if a person who is not specially trained can do grossly harmful things to people, then the current protections afforded by the marketplace are not enough,” he said.

The current reliance on malpractice suits to weed out incompetent doctors does not work, Caplan said.

“Medicine is never going to get itself out of the courtroom and the see the high cost of malpractice insurance fall until it finally decides to take seriously the problem of incompetent doctors.

“Now do I realistically think that’s going to happen? Well, no.”