Cosmetic Surgery and Safety
Thursday, July 30, 2009
Recently, a Coronado plastic surgeon allowed physician assistants to perform liposuction, prompting this question: Is cosmetic surgery safe? We'll chat with a local doctor.
Going in for a little cosmetic rejuvenation has become an accepted part of the Southern California lifestyle. There are hundreds of doctors and medical clinics dedicated to making us look better. And the number of procedures available has exploded in recent years. Cosmetic surgery isn't just about face lifts anymore. There are dozens of less invasive procedures to remove wrinkles, tighten skin and re-contour the body.
But, as common as these procedures are, that doesn't mean they are without risk. Critics say the industry is still poorly regulated. And just recently, a cosmetic surgeon in Coronado is alleged to have violated a number of medical standards, including allowing his assistant to perform liposuction when he was out of the office.
Host: Maureen Cavanaugh
Guests: Dr. Mitchel Goldman, Medical Director of La Jolla Spa MD
MAUREEN CAVANAUGH (Host): I'm Maureen Cavanaugh. You're listening to These Days on KPBS. Going in for a little cosmetic rejuvenation has become an accepted part of the Southern California lifestyle. There are hundreds of doctors and medical clinics dedicated to making us look better. And the number of procedures available has really taken off in recent years. Cosmetic surgery isn't just about facelifts anymore. There are dozens of less invasive procedures to remove wrinkles, tighten skin and re-contour the body. But, as common as these procedures are, that doesn't mean they are without risk. Critics say the industry is still poorly regulated, and just recently, a cosmetic surgeon in Coronado is alleged to have violated a number of medical standards, including allowing his assistant to perform liposuction when the doctor was out of the office. Joining me to discuss how cosmetic clinics and doctors are regulated and some of the problems patients encounter is my guest, Dr. Mitchel Goldman. He’s a former clinical professor of dermatology at UCSD and medical director of La Jolla Spa MD. And, Mitch, welcome to These Days.
DR. MITCHEL GOLDMAN (Medical Director, La Jolla Spa MD): Good to be here, Maureen.
CAVANAUGH: I want to tell our listeners that we invite them to join the conversation. What do you think people need to know before they go in for a cosmetic procedure? Do you have a story you’d like to share? Give us a call at 1-888-895-5727. Now I think we should start out with just a sort of overall idea about the number of cosmetic procedures there are available now and how that has grown. You know, people used to talk about going in for a little nip and tuck but now there are, I mean, a plethora of different things that people can go to a clinic for: skin tightening and laser hair removal. What are some of the other procedures?
DR. GOLDMAN: There are so many from trying to make your muscles not as strong by using something called Botox or Dysport, to filling up depressions on the skin or wrinkles with a variety of products called Restylane and Juvederm, to actually performing a liquid facelift with a product called Sculpture that just got its FDA approval yesterday for that reason. So now you don’t have to go into the doctor’s office and expect to have a big surgery and blood and stitches and everything like that. Now you can basically go in and with a few injections that are just about painless, walk out looking a lot better than when you came in.
CAVANAUGH: Now I wonder, though, is there a feeling among patients that these less invasive procedures don’t require as much medical supervision?
DR. GOLDMAN: Maureen, that’s the problem. The problem is that they’re so easy to do and you think anyone with a needle and a syringe can just inject stuff, and that’s exactly what’s happening. It’s not that easy. You have to know what you’re doing, you have to be well trained in what we call the core physicians, which are the dermatologists, the plastic surgeons, cosmetic surgeons, facial plastic surgeons. But now, you’ve got the retired proctologists, the OB-GYNs, the pediatric neurologists, that are all getting into the act because they see it as a money-making procedure. This is especially problematic because insurance reimbursement is so poor that all of these other specialties are trying to make some money and so they think, hey, I can inject something into someone’s face. And the problem is that we see horrendous results on – literally, on a daily basis.
CAVANAUGH: Well, what kind of regulations are in place in California’s – about who can run a cosmetic spa or a clinic?
DR. GOLDMAN: The truth is any physician with an M.D. or D.O. after their name can run one of these clinics. But the problem is that oftentimes the person that allegedly is running the clinic is a pediatric neurologist who is vacationing in the Indian Ocean and one of the nurses is actually performing the procedures. And if something goes wrong, which in this one case actually something did go wrong, they couldn’t even get ahold of the person. There’s others where the plastic surgeon supervising the clinic is in Iraq serving in the military and so I don’t know how a doctor can be in the Indian Ocean or in Iraq and have responsibility for servicing a clinic. And this is the problem that’s happening. Very well-meaning nurses are basically doing things for pay and for profit to people without adequate supervision. And that’s the key, is the lack of adequate supervision. You know, we, as dermatologic surgeons, we have a bill that’s now before the governor to actually mandate that there is a physician in the facility. That’s about the least. In the State of Florida, it has to be a dermatologist or plastic surgeon within a facility doing these procedures. But here, all we want is a physician to be available, and who knows if the governor’s going to sign it because it’s going to – because this cosmetic surgery business is a billion dollar business and so, obviously, there’s lots of lobbyists out there trying to say, oh, no, you don’t have to sign it, we can just let all the nurses do everything.
CAVANAUGH: Tell us about one or two of the problems that you’ve seen of people being injured by these poorly performed cosmetic procedures.
DR. GOLDMAN: Well, the injury is both to the face as well as to the pocketbook. The most common injury is someone going to a laser hair removal clinic and being promised permanent hair removal if they just pay this amount of money, $2,000, $3,000, and you can come back for unlimited visits. Now, we all know that laser hair removal’s not permanent. It lasts for a long time but permanent is when you die and that just doesn’t happen. And so what ends up happening is after a year or two, the laser clinic goes out of business and so these people are – have spent thousands of dollars and there’s no one to do the treatments. Other times, people are getting treatments and they get white scars and other types of problems, depressions on the skin, elevations from improper injections, and there’s no one at the clinic that will take responsibility because, oftentimes, if not all the time, the doctor’s not even there.
CAVANAUGH: I wonder, you know, when – when a case of abuse is brought before the California Medical Board, what do they do when it comes to cosmetic procedures? What kind of action do they take?
DR. GOLDMAN: Yeah, unfortunately, very little. We actually testified before the Medical Board last year and the problem that the Medical Board has is, of course, like much of in this state, they’re totally under-funded and they’re totally overwhelmed, and so they don’t have the ability to actually go out and really police things unless it’s egregious. And the Medical Board basically told us that, hey, has anyone died from this? And the answer is no. People don’t necessarily die from an injection of Botox or that’s improperly done or Restylane or some other procedure but they are financially harmed from unscrupulous people and they have procedures done which are inappropriate that will take time to heal but usually there is time to heal and sometimes it’s a scar but it’s just a scar. And so the Medical Board said, look, when you have evidence of people dying, then we’re going to really get on this. But until someone drops dead from a horrible procedure, which is unlikely to happen, you know, the Medical Board has other things to do like trying to regulate impaired physicians or, as you said, physicians that allow their staff to perform invasive, life-threatening procedures without even being in the building.
CAVANAUGH: I’m speaking with Dr. Mitchel Goldman. He’s a former clinical professor of dermatology at UCSD and Medical Director of La Jolla Spa MD. And we are taking your calls at 1-888-895-5727. You know, you really can’t open up a lot of magazines in San Diego without just seeing a huge number of ads for cosmetic surgery procedures, all sorts of procedures, cosmetically based, and, you know, lately I have seen some about ads for discounts. Discount Botox, discount things of that nature. Where does that come from and who administers that?
DR. GOLDMAN: Well, sometimes it’s done by a real dermatologist or plastic surgeon and it’s done where they’re doing it below cost just to try to get the patients in to do a breast augmentation or a facelift. But most often it’s done by a nurse and it may be with a product that’s not an FDA approved product but one that’s purchased out of the country. And the problem when you’re purchasing even a medicine like Botox out of the country, or Restylane, there’s no assurance that the Botox or Restylane has been properly stored and transported and so when you’re paying that $8.00 a unit for Botox, you don’t know if it’s the real stuff or if it’s basically not as powerful because it has not been stored properly. And so you’ve got to really – you know, you get what you pay for in these days, and the other thing that our moms always told us, if it’s too good to be true, it is. And we just have to use common sense. Now, yes, some of the places are very reputable that are doing this and it’s basically the hard sell once you put your money down to get something, they try to upsell you to something else. But, you know what I tell all of my friends and patients and our listeners, is that you’ve just got to use your common sense and you need to go to one of the board specialized dermatologists, cosmetic surgeons, plastic surgeons, because it’s your face we’re talking about. It’s your body. And if you – if it gets screwed up, it’s a big problem to you.
CAVANAUGH: Exactly. Now when you mentioned this new procedure that’s out, this liquid facelift that’s just been approved by the FDA, I imagine that most cosmetic procedures are approved by the FDA or some other board. But I wonder, are there some things that you hear about that you say, you know, that just doesn’t sound right. I don’t think that that’s a proper procedure. And yet it’s being performed in clinics and it’s something that people know about.
DR. GOLDMAN: Yes, and it’s most common with the laser procedures. And even though I have over 30 lasers in my office, every laser’s very different and the FDA doesn’t approve lasers necessarily for a specific indication, they clear them as being safe so that there are a lot of lasers that come to the market that have a high popularity because they’re seen on “Oprah,” and Oprah says they’re phenomenal and the machine actually wasn’t even turned on and so that’s another thing that we can talk about but we don’t want to dis Oprah on the radio. But, you know, those are problems and then it gets into a magazine and people go, wow, there’s this phenomenal – there’s this new laser that’s being promoted in San Diego with these practically full page ads and the San Diego Union saying all you have to do is sit in this room, pay us $3,000.00 and six inches will come off of your abdomen. And there’s never been one scientifically verified, proven study to say that but yet this stuff is in the San Diego Union because they just need the advertising dollars. And so, again, it’s just common sense, buyer beware. You know, if it’s too good to be true, it is.
CAVANAUGH: You know, I was surprised to see that some cosmetic procedures are actually now being advertised on television. I saw an infomercial about a cosmetic procedure that is virtually a lunchtime facelift, sort of something that is supposed to change how your face looks and it’s supposed to have no anesthesia and so forth. What should people be – Should people be concerned when they see things like this?
DR. GOLDMAN: Yeah, they really should. But it’s so difficult to police this. But, again, it’s the common sense and it’s to ask – If you go to that clinic in curiosity, ask to see the before and afters, ask to – ask to talk to some of the people that have gotten the procedure. You know, see the proof. It’s like where’s the beef? It’s – You’ve got to question. You can’t just go into this thing and because someone has a white coat, they’re telling the truth because oftentimes the person in the white coat isn’t even a physician.
CAVANAUGH: Right. Now do you think more people are putting their concerns to the side and going for a discount because of the recession that we’re in?
DR. GOLDMAN: Yes and no. I – I see that occurring. Most commonly, it’s a bunch of girlfriends getting together and going, oh, let’s all do this together and – and that they – one of them may be getting a kickback and the other ones don’t know and so you can’t have Botox parties, you can’t have cosmetic surgery parties. You can’t always do what your girlfriends are doing. You got to really look into it a little bit more.
CAVANAUGH: We are taking your calls at 1-888-895-5727. My guest is Dr. Mitchel Goldman. He’s a former clinical professor of dermatology at UCSD and currently Medical Director of La Jolla Spa MD.
DR. GOLDMAN: Maureen, just one thing.
DR. GOLDMAN: So that UCSD doesn’t get really upset with me, I’m actually still a volunteer clinical professor. I haven’t resigned. So if the chairman’s listening, it’s like, boy, I haven’t resigned, don’t worry about it. I’m still on staff.
CAVANAUGH: Gotcha. Now I’m wondering, you say the buyer has to beware when it comes to cosmetic surgery and the doctors that perform the procedures. But specifically what is it they should be – beware of?
DR. GOLDMAN: Experience is the most important thing. You need to know how many patients this physician has treated, what their experiences, what their board specialization, and then do they have the before and after pictures to show you? Now oftentimes, I’ll be honest, it’s difficult to take good before and after pictures and so sometimes what we have is we actually have patients that’ll allow us to have other people call them. And, of course, in – You have to be very, very careful these days. You can’t give out a lot of information. People really want their privacy. But those are important things, as well.
CAVANAUGH: And what are the signs, perhaps, of an operation that is poorly run and that you should – should not go to?
DR. GOLDMAN: When the – when you never meet the doctor, that’s your number one thing. If you go in there and it’s nurses that are hard-selling you on procedures and you never even get to see the doctor, it’s like that’s your first clue to just get up and run away. And then the other one is look at the specialization. How long has that physician been here in San Diego? You know, is it someone who’s been around for 20 years or someone that just came in last year from Las Vegas or from another area? And, you know, it’s – again, it’s common sense.
CAVANAUGH: We have a call, and Anthony is calling from Miramar. Good morning, Anthony, and welcome to These Days.
ANTHONY (Caller, Miramar): Thank you, and thank you for taking my call. Yes, I had a question for the – for the doctor. Is now I’ve seen these commercials on television for lifestyle lift and you see before and after photos of these people who are in their mid-fifties, men and women, and the contrast is quite striking. I’m thinking, is that actually real? I mean, they said, oh, it took no time at all, just an hour in the office and here, these are the results, it’s just fantastic. And you see some very super fine small print that you can’t read before the commercial is over, so I was wondering if you could answer that question for me. And I’ll take my answer off the air.
DR. GOLDMAN: Yeah…
CAVANAUGH: …you, Anthony.
DR. GOLDMAN: Thanks, Anthony. Well, the fine print basically says this is not representative of all the patients. The thing is, the lifestyle lift is basically a very minor facelift that was performed decades ago, which was then sort of dropped because what happens is the results are really good for a few years but only for two or three years and then they – basically, everything falls apart again. And what this company does is, you actually have to spend money to be on their website and take a weekend course and, you know, truthfully, many different physicians can do a lifestyle lift and there are the retired proctologists out there that are doing lifestyle lifts with just a weekend course of training. But I don’t want to knock it completely because there’s some really good physicians that are also doing a lifestyle lift and there are some patients out there that don’t need to have a full facelift that might only need to have a little bit of a nip and tuck. And so, again, it all depends. If you’re going to go for that, you know, basically make sure that the physician is well qualified, is Board specialized in cosmetic or facial plastic surgery, and that they’re competent to do the procedure.
CAVANAUGH: I wonder, Doctor, how hard has the recession hurt cosmetic surgery?
DR. GOLDMAN: Well, it’s hurt it really hard. The plastic surgeons def – are down 50 to 70%, 2008 over 2007 and ’09. And most of the dermatologic surgeons are down much less. To be truthful, our practice was down about 16%. What’s happening is – are the big ticket items, the liposuctions, facelifts are down, and the breast augmentations. But what’s up are the little procedures because, you know, the Botox is up, the Restylane, Juvederms are up, Sculpture is up. And the reason the little procedures, which are procedures less than $1,000.00, are up is people still want to look really great. People are out of work and they’re competing against younger people and they want to look their best and they want to increase their self-esteem. And so we’re doing a lot of the smaller, less than $1,000.00 procedures. Those are really popular.
CAVANAUGH: Let’s take another call. Cindy is calling from San Diego. Good morning, Cindy. Welcome to These Days.
CINDY (Caller, San Diego): Good morning, and thank you for having me on. I have a couple of – one is a question and one is a comment. And the first question is, is there not supposed to be a board certified anesthesiologist onsite for some of these procedures? Because I believe that the highest rate of mortality is associated with the administration of anesthesia. Number two, is regarding before and after shots, the before shots are frequently taken with low light and the after shots of the person’s face is blasted with tons of white and contrast so you can’t really tell whether or not there are any imperfections. And I will take my answers off the air. Thank you.
CAVANAUGH: Thank you so much, Cindy. I guess the anesthesiologist doesn’t even really apply to a lot of the procedures that we were talking about.
DR. GOLDMAN: Yes, but what she’s talking about is a lifestyle lift sometimes only requires a local anesthetic but where a number of plastic surgeons are sort of cutting costs is have a nurse anesthetist administer anesthesia for full facelifts or breast augmentation instead of having a board certified anesthesiologist there. We have a board anesth – board certified anesthesiologist in every procedure where we do general anesthesia. Whether that’s a difficult – whether that’s harmful to the patient, it’s like, you know, I don’t want to totally dis the nurse anesthetists but at least in my practice we always have a board certified anesthesiologist and I – I do think that’s the better way to do the procedure. Regarding the before and after pictures, you know, it’s very problematic. You’re absolutely correct in what you’re saying, Cindy. And when you see those, the only thing you can do is send it to the Medical Board of California and one day they eventually get around to regulating it but it’s a very difficult thing. But you’re being very smart and perceptive when you look at those before and afters.
CAVANAUGH: I’m wondering, do you think that if more cosmetic procedures were actually covered by insurance that that would help shape up the industry?
DR. GOLDMAN: Shoot, I don’t know because the problem will be the insurance will want to do it for the cheapest possible and then you get the retired proctologists and other people doing it and the doctors sort of standing in the corner and supervising three operating rooms at the same time with physician assistants doing it. So I don’t know about that one.
CAVANAUGH: What can do – Is there sort of – If the public got involved in asking for tighter regulations, would that help?
DR. GOLDMAN: It surely would. And if the governor would actually – And even though I like doctor – Arnold Schwarzenegger, he’s a good guy, but – and he’s under a lot of pressure, but he can’t just do what’s right for the business community. He has to do what’s right for the people of California. And so I really hope that our governor does sign this legislation to make sure that the cosmetic procedures are being done safely and effectively by property trained Board certified dermatologists and plastic surgeons.
CAVANAUGH: Well, I want to thank you so much for speaking with us today.
DR. GOLDMAN: Thank you, Maureen.
CAVANAUGH: I’ve been speaking with Dr. Mitchel Goldman. He is a clinical professor of dermatology at UCSD, and Medical Director of La Jolla Spa MD. And I want to thank everyone who called. Sorry if we didn’t get a chance to take your call on the air but you can continue this discussion online. We want to encourage you to post your comments at KPBS.org/TheseDays. And stay with us for the second hour of These Days coming up in just a few minutes.