At What Cost Beauty?

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It was not that long ago that the term makeover suggested little more than a new eye shadow or a dye job. Now it is just as likely to result in a straighter nose, larger breasts and a brow that won't furrow when confronted by even the most noxious odor. That attaining such features often involves anesthesia, injections, incisions, blood and a professional with at least seven years of medical training is a distinction increasingly lost on the general population.

But plastic surgery does mean going under the knife, and lately there have been plenty of reminders of the risks involved. From May 2003 to January 2004, five people in Florida died following cosmetic plastic surgery, prompting the state's board of medicine to open an investigation. All five, ranging in age from 38 to 63, had their operations done in doctors' offices. One had a breast augmentation; another, surgery on his eyes, chin and neck; another had liposuction and a fat transfer; and two, liposuction and tummy tuck. Citing an "immediate danger to public health," the board issued a 90-day moratorium on the two procedures being performed together in a nonhospital setting. A 54-year-old woman, the wife of a cardiologist, died of complications from plastic surgery last week while undergoing a procedure at one of New York City's most prestigious hospitals, the Manhattan Eye, Ear and Throat Hospital, run by Sherrell Aston, husband of socialite Muffie Potter Aston. This is the same location where last month, in a case that made national headlines, The First Wives Club author Olivia Goldsmith, whose work often celebrated and satirized plastic surgery, died after seeking a cosmetic procedure. Both women died of complications from anesthesia.

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The vast majority of cosmetic procedures — both surgical, such as face-lifts and liposuction, and nonsurgical, like Botox and collagen injections — conclude without incident. But with the number of these operations growing--8.3 million in 2003, a 293% increase from 1997--things can end badly more often. Part of the problem may be that it is not necessary, from a legal standpoint, to be trained as a plastic surgeon to practice plastic surgery. All a person needs is a medical degree. Doctors can choose to become certified by the American Medical Association — recognized American Board of Plastic Surgery. For that, they must complete seven years of training, including a three-year residency in general surgery and at least two additional years of a residency in plastic surgery. But many doctors don't bother with the special training and practice the surgery anyway to supplement their incomes. Only two of the five doctors in the fatal Florida cases were board-certified. The woman who died after a breast augmentation was operated on by a doctor who specialized in dentistry.

Since doctors have the right to perform such operations, it is up to the patient to monitor their backgrounds and decide whether he or she feels comfortable with their training. A patient should also investigate the facility where a procedure would be performed. Technological advances have made it possible to perform intricate surgeries in nonhospital settings on an outpatient basis. Some are done in private, freestanding surgical centers, others in doctors' offices.

Patients often enjoy a doctor's office because it feels more personal; many doctors prefer it because they exercise complete control over their surroundings and costs. That can be perfectly safe as long as the offices maintain safety precautions, but some state and local governments do not monitor whether they do. The task can be left to accrediting agencies. States may require offices to be accredited, but the agencies perform inspections and give the seal of approval. The one considered the gold standard is from the American Association for the Accreditation of Ambulatory Surgery Facilities (AAAASF). To receive its blessing, doctors must be board-certified in their field, and their facilities must prove they have the means to handle emergency situations. The problem is that getting inspected for accreditation is done on a voluntary basis. Says Michael McGuire, a Los Angeles cosmetic surgeon and the AAAASF's president: "Facilities open, and nobody knows on a state level that they are there."

Why — or whether — the liposuction — tummy-tuck combination is particularly hazardous in a doctor's office is a question the Florida board is investigating. It is not uncommon for people to have multiple procedures performed at once, and when the patient is in good health, it is not especially perilous. But generally, undergoing more than one procedure not only prolongs recovery but also increases the time a patient is anesthetized, which can be risky. "I personally don't believe in procedures that go beyond five or six hours," says Dr. Robert Bernard, who operates in his Westchester, N.Y., office and is the president of the American Society for Aesthetic Plastic Surgery, whose members are all board-certified. "If somebody comes in and wants their face, eyes and nose done, that's O.K. But if they want that as well as breast reduction and a large amount of liposuction, I'd prefer to divide it into two procedures."