Medical Tourism and Plastic Surgery

Wednesday, February 11th, 2015

One of the great things about Fort Worth is the ease of access to the world afforded by DFW airport. American Airlines has its headquarters here in town and DFW is its largest hub. With U.S. based airlines like United, Delta, and Spirit, it's easy to either fly here from anywhere in the country, or to fly from here to anywhere else. DFW now even has nonstop flights to and from Australia on Qantas, the UAE on Etihad and Emirates, Seoul on Korean Air, and a number of carriers to many places in Europe.

So, why am I talking about this on my plastic surgery blog? Because of medical tourism. It has become all the rage. Forbes magazine estimated that 1.25 million Americans would travel abroad for some type of medical care in 2014. That number seems a bit high to me, but it's Forbes and they seem to know a lot about numbers. The point of the Forbes article is that Americans are traveling to other countries for care. Costs for many treatments and many surgical procedures are higher in the US than many other places in the world. If quality of care is high, outcomes are good, and cost is low, why not go?

Seoul, South Korea, is one of the "hot spots" listed in almost any article about medical tourism. Apparently Chinese citizens are traveling there in throngs to undergo cosmetic surgery. The Ritz Carlton in Seoul even partnered with hospitals there, offering an "anti-aging beauty package" for a mere $88,000 (US dollars). Sounds like a bargain! Other popular places people are going for surgical procedures include Costa Rica, India, and Mexico. To see what all the fuss is about I thought I'd check into what it would cost for a woman to undergo breast augmentation in each of these four hot medical tourism destinations: Seoul (Korea), San Jose (Costa Rica), Mumbai (India), and Monterrey (Mexico). As a comparison, breast augmentation in Fort Worth typically costs somewhere between $4,000 and $5,000, depending on the specific breast implants used. This cost includes the breast implants, surgeon's fee, facility fee, anesthesia, and preoperative and postoperative visits. Different surgeons charge different amounts, but I believe the total cost of $4,000 to $5,000 is about right for Fort Worth. If you travel to Seoul, be prepared to pay about $6,000 for your augmentation. Monterrey Mexico? About $4,000. Mumbai: about $3,800. Costa Rica will also cost about $3,800. Interestingly when looking at websites that promote international medical tourism, I found that those websites typically list the "average" cost of breast augmentation in the US to be $9,000. Gulp. $9,000!! So of course it seems like $3,800 in Costa Rica is a huge bargain when you compare it to $9,000. There probably are places in this country that charge $9,000; I just don't know where. Maybe Manhattan? But really, when you compare the cost of breast augmentation in Fort Worth, Texas to those four "hot spot" medical tourism destinations, it almost makes me wonder why anyone from North Texas would travel to one of those places to undergo this type of cosmetic surgery.

Having been a plastic surgeon in Fort Worth for 20 years, I have had the privilege of performing cosmetic surgery for women not only from all areas of Texas but also from places like California, Canada, New York, and Florida. DFW airport makes the travel easy, but it's our outcomes that make it even possible. I do surgery in hospitals and ambulatory surgery centers that undergo strict accreditation processes. If you want to see a hospital administrator sweat, tell her that The Joint Commission (formerly known as the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO) is coming to do an inspection of the facility. The Joint Commission has created and continuously improves strict sets of standards and clinical practice guidelines that hospitals and other facilities must meet or exceed if they want to continue providing care for patients. Failing a Joint Commission Survey means a facility may have to close. Facilities are inspected every three years. It is through inspections like these that surgical facilities in the United States maintain some of the very highest standards in the world. The Joint Commission doesn't just look at the physical layout of a surgical facility. It also inspects things like the credentialing process the facility uses to make sure that the doctors who work there are qualified to do the things they are doing. For instance, if I want to do breast augmentation surgery at a facility, the facility needs to make sure that I have completed appropriate training and have met certain national and community standards. Board certification by the American Board of Plastic Surgery is one measure that facilities use to help them make sure a surgeon is qualified to perform cosmetic surgery. The facilities also request information about where a surgeon did his or her training, about malpractice suits, and about having a medical license to practice in that state (in my case, Texas). The American Board of Plastic Surgery has its own rigorous process regarding certification of plastic surgeons. This all sounds great, but if you are still reading you're probably getting a little bored by now. The point of all of this is that if you undergo breast augmentation in Fort Worth, Texas by a plastic surgeon who is certified by the American Board of Plastic Surgery, you have a pretty good idea about the qualifications of the facility and the qualifications of the surgeon who is doing your surgery (preferably me!). Can you really say that about undergoing breast augmentation in Costa Rica or Mexico or some other country? Maybe, maybe not. Certainly different countries have requirements regarding who can do what as far as surgical procedures are concerned. One of the biggest problems is that we, as consumers, don't really necessarily understand what those qualifications are. Are standards regarding sterilization processes of instruments the same in India as in Dallas? Maybe. What about standards regarding immunization status of the personnel who will be taking care of you? The same in all places, or different, and does that really matter? In the U.S., you know that there are amazingly high standards of care. There may be similar high standards in all of these hot spot medical tourism destinations as well, but it's just not as clear.

Now, suppose you take the next step and actually go to another country to undergo breast augmentation. Maybe you're thinking, hey, it costs a little less (excluding the travel, of course), you've researched what you can, and what the heck, there's a little vacation thrown into the mix. After all, travel to Costa Rica can be pretty exciting. Monkeys, exotic butterflies, rain forests...just an amazing place. But when you are being wheeled into the operating room, do you know what implants are going to be used? Different countries have different implants available. Just ask women in France how they liked their PIP implants. That company used industrial grade silicone rather than medical grade silicone for their implants, the implants had twice the rupture rate of other implants, and the head of the company was sentenced to four years of prison for fraud. While those implants are no longer even available, they were available and being used at one time. Knowing specifics about the breast implants that will be used is really important. Also, will there be a warranty with the implants being used? Probably, but you better make sure. And making sure might be kind of difficult. While your surgeon probably speaks and understands English well, most of the staff responsible for getting you safely through surgery and the recovery area probably don't.

Medical tourism is a growing industry. Travelling abroad is exciting, and people usually have good results. There are some uncertainties, though, that are worth considering as discussed above. Here in Fort Worth we see patients from all areas of Texas as well as from all over the country. The distances some of these people travel make this, too, a form of medical tourism. However, undergoing surgery in the U.S. does provide some certainties regarding standards. Language is not usually an issue. Cost definitely varies around the country. In my experience costs for cosmetic surgery are lower in Fort Worth than almost any other city of similar or larger size in the U.S., and similar (at least for breast augmentation) to costs in the international hot spots for medical tourism. So, skip the passport and the immunizations! Jump on American Airlines or Delta or United or Spirit or load up the car and come on down/over to Fort Worth. It's a great city with a vibrant art scene and cool downtown, nice places to stay, and all kinds of interesting places to eat. My office is in the downtown medical district and we would love to have the opportunity to help you fine tune your image!

Shaped Silicone Breast Implants ("Gummy Bear" Implants)

Thursday, February 5th, 2015

More and more women are asking about shaped silicone gel breast implants. There are other names that people use for these types of implants, including "form stable", "cohesive gel", "gummy bear", and "5th generation" implants. As the name suggests, these implants have a shape to them; they are not round. Shaped silicone breast implants provide a different look than round breast implants. They have a tapered shape, being a little thin at the top and thicker at the bottom. Because of this shape some people think of a "tear drop". These are called 'form stable' implants because, unlike round implants, when you place shaped silicone breast implants on a firm surface, they maintain their shape. Round breast implants, on the other hand, do not maintain the same shape in the upper part of the implants when they are placed on a firm surface. Women who choose shaped silicone gel breast implants typically are hoping to achieve a somewhat tapered appearance of their breasts, with a gradual transition from the chest to the breast. Shaped silicone implants may not provide the same projection (front-to-back dimension) as a similar volume round implant. The look that 375 cc shaped silicone implants provide may be moderately different than the look obtained from 375 cc round implants, with less projection but perhaps more height with the shaped breast implants.

The reason that shaped silicone gel breast implants maintain their shape is that the silicone gel is formulated differently than the silicone gel in round silicone breast implants. The gel is more firmly bonded in these implants than round breast implants. While not an exactly accurate analogy, it is kind of like the difference between having jello in a ziploc bag versus having water in a ziploc bag. If these two bags are placed on a table, the bag with jello will have more height to it than the bag with water. The jello is bonded differently than the water. People sometimes refer to shaped implants as "gummy bear" implants because if a shaped silicone implant were to be cut in half, the silicone does not leak out. It is a similar consistency to a gummy bear candy. If a round silicone gel breast implant were to be cut in half, the silicone would eventually leak out and the implant would lose its shape.

Women who choose shaped silicone breast implants choose them because they are looking more for a shape rather than a size. Women who want to wear a certain size bra, perhaps a full C or D cup, may be happier with round implants. While shaped silicone breast implants may also provide a full C or D cup result, there are some nuances in using these implants that need to be thoroughly discussed.

I participated in one of the original studies that led to FDA approval of shaped silicone gel breast implants (Allergan style 410 implants) and have been using them for several years. If you come visit with us in the office regarding breast augmentation we will certainly talk with you about all of the breast implant styles available. We do not choose the implants for you, but instead help you understand the differences between the different breast implants and how they may affect your final look. Call the office and come learn about breast implants!

Vectra 3-dimensional imaging in Fort Worth

Thursday, September 5th, 2013

We are the first medical practice in Tarrant County offering the Vectra XT imaging system. This is truly a "Wow" device! Six cameras take pictures of you, then a computer takes those six pictures and reconstructs one 3-dimensional image. We can then do some amazing things with this 3-D image. The image can be rotated and twisted, allowing us to show you parts of you that are hard to see in a mirror. As part of the educational process, we can draw on the image to show you, for instance, where incisions may be required or to point out specific findings to make sure that we are talking about the things that are most important to you. For our breast augmentation patients it's even better. Information about every breast implant currently available in the US is stored on the computer. We can take the 3-dimensional image of the woman's chest and pick a specific size, shape, and volume implant. Click a button and voila! The computer creates an image of what the result of those specific implants might look like in that specific person. Want to see what a different set of implants might look like? Click, done. We have also found this to be very useful in our breast cancer patients. In those women it helps us tailor the final result to more closely match the size and look of the reconstructed breast to the breast without cancer. While this imaging system does not tell us exactly what someone's final result will be, we have found it to be a wonderful tool in helping our patients understand possibilities. Vectra has been, for our practice, an incredible enhancement to the entire educational process for our patients. Come see it for yourself! We're the first in the area to have it!

Girls' Night Out

Saturday, February 4th, 2012

We are going to have another of our Girls' Night Out events this Wednesday, February 8th, from 6 to 8 pm at our 8th Avenue office.  Each of our events, taking place three or four times a year, has a unique theme.  The theme for this event is "Beauty with Friends".  Our aesthetician, Lori Roby, will talk one-on-one with guests about some of the great products and services she offers.  Our clinical nurse injector, Krista Barrington, will demonstrate Botox injections on one of our current clients.  And of course, I will speak a little about surgical options over any number of topics, tailoring the discussion to the women present that evening.

These events also raise money for local organizations that provide special care and services that blend with the needs of many of our patients.  Previously we have donated portions of the proceeds from these evenings to the Joan Katz Breast Center (link:   http://www.wfaa.com/good-morning-texas/Celebrating-the-Opening-of-Joan-Katz-Breast-Center-92340909.html), and the local Komen Foundation ( link:  http://ww5.komen.org/).  For the February 2012 event, the recipient is Cuisine for Healing (link: http://www.cuisineforhealing.org/).  We are excited to partner with these groups.  Sue Austin from Cuisine for Healing will be present Wednesday evening and you can learn all about it from her.

Another terrific local organization that also offers special services to our breast cancer patients is Indigo Yoga (link: http://www.indigoyoga.net/).  Brooke Hamblet Hinkle, Founder and Director, will also be present Wednesday.  Come visit with her to learn about yoga may be of benefit to you or someone you know!

These are not just boring little wine-and-cheese events.  The office staff kind of goes 'over the top' in putting these evenings together.   Come join us and see for yourself.  Bring a friend!  Call the office and make a reservation because, darn the luck, the fire marshal only allows so many people in the building at one time!







And the winner is...

Friday, January 6th, 2012

Award:  a prize or other mark of recognition given in honor of an achievement.

Reward:  something given or received in return or recompense for service, merit, hardship, etc.

       I am fortunate to have been awarded listing in Fort Worth, Texas magazine's Top Docs list numerous times and Texas Monthly magazine's Texas Super Doctors list for five consecutive years.  These lists are created by physicians voting for doctors they think represent the best in their respective fields of medicine.  To me these awards recognize not just the surgical outcomes achieved but also the complete patient experience accomplished in our office.  This includes the level of care patients receive by the entire office staff, from how they are handled when they call the office to the caring attitudes they encounter during their postoperative visits.  Being voted to these lists is an honor that recognizes  complete team involvement, and I am grateful to be part of a great team in the office.

       Perhaps more rewarding, however, are the relationships we develop with our patients.   Having just completed another holiday season, I am humbled every year by the number of patients who bring candy, tamales, popcorn tins and other thoughtful items to the office.  This illustrates, in a way, the relationships developed over time not just with our cosmetic clients but with our breast and skin cancer patients as well.  Awards like being named to Top Docs and Super Doctors lists are gratifying, but the rewards of developing unique relationships with our patients are truly meaningful and drive us in our practice.  Thank you to the doctors who have nominated me to these lists and to the patients who make this practice so remarkable.

(Here is a video of the Top Docs recognition event for 2011; I am briefly shown at the 2:05 mark: Top Docs video )

Texas heat...be safe!

Monday, July 4th, 2011

As the heat cranks up the deeper we go into summer here in North Texas, I am reminded of my first weekend on-call during my plastic surgery training. Entering the training program, I remember thinking that there probably wouldn't be too much need for a plastic surgeon in the emergency room, other than a few lacerations. That way of thinking changed quickly.

My pager went off (cell phones were in their infancy and few people had them) that first Saturday afternoon, and it was the University Hospital emergency room telling me about a patient. He was a young man, about 23, who had been on a boat with some friends. They were having fun, water skiing, having a few beers. As the day wound down and the last skier was climbing back into the boat, this young man did what anyone who skis has done many times. He started to pull the rope in. As he did that, he wrapped the rope around his upper arm and the 'V' between his thumb and index finger, going around and around. After he had done this wrap a few times the guy driving the boat, who incidentally had only had "a couple beers", punched the throttle forward. The boat lunged forward while a bunch of the ski rope was still dragging behind the boat. In an instant the entire rope jerked tight, snapping around the young man's upper arm and severing it. The entire arm was yanked off in the middle of the upper arm, and it fell into the water. Someone dove in after it, retrieved it, and somehow they managed to bring the man and his arm to the emergency room.

Let that scenario sink in for a second.

There are just so many things that we do that we take for granted. Water skiing and drinking beer? It almost seems like there is some sort of statute here in North Texas that says you can't go skiing without having a cold one around. Wrapping the ski rope as you pull it in? How else are you going to get the rope into the boat? This was another situation where everyone was having a good time but someone just didn't pay attention for a second. And that second meant the difference between a nice day versus losing an arm (we couldn't save the arm).

We have a severe drought in North Texas this year and the lakes are low. Tree stumps lurk close to, but below, the lake surfaces. Be careful if you're out on the lakes in the next two months. Take that extra second or two to be aware, to be safe. And remember, if you're the one driving the boat, you shouldn't be drinking cocktails (or beer!).

By the way, the same is true with fireworks. Some day maybe I'll write about my experience with those from a plastic surgeon's perspective.

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