Cosmetic surgery abroad sounds glamorous and costs half as much, but is it safe?
by Laura LaFay

Priscilla Anderson went to Costa Rica for two weeks in 2004 and got a tummy tuck with muscle repair and a breast lift with implants for $5,400 – less than a quarter of what two different plastic surgeons in Minnesota said they would charge. She liked her surgeon and was satisfied with the results. A year later, when one of the implants shifted, he fixed it free of charge and, while he was at it, did some liposuction on her upper arms and inner and outer thighs. Once again, she was happy with the results. So happy, in fact, that she plans to return to the same surgeon for another procedure this year.

Jodi Schapiro went to Argentina in 2006 for a tummy tuck, facelift, breast implants replacement and lower-body lift. The same combination of procedures would cost $32,000 or more in the U.S., but Schapiro’s Buenos Aires surgeon charged only $4,900 and promised to repair the deviated septum of Schapiro’s Argentinean boyfriend into the bargain. But things went wrong almost from the beginning.

Instead of cutting horizontally from hip to hip during the tummy tuck, the surgeon, Dr. Mario Lodolo, cut vertically from breastbone to groin, leaving a jagged wound. And instead of the promised facelift and implants, he removed one third of her vagina in an apparent attempt to perform a procedure that Schapiro says she never even discussed with him.

Left to recover in an apartment without antibiotics or painkillers, Schapiro had a heart attack and spent three days near death in a Buenos Aires hospital for indigents before her boyfriend’s brother managed to get her secretly admitted to a military hospital. By the time she made it home to Miami, she had septicemia. Hospitalized again, she lapsed into a coma. Now, more than a year later, she is under treatment for Post Traumatic Stress Disorder and still so traumatized by the ordeal that she cannot even consider reconstructive surgery.

These are boom times for cosmetic surgery. Fueled by reality shows like Extreme Makeover, Nip/Tuck and The Swan, the number of cosmetic surgery procedures performed in the U.S. has risen 446 percent since 1997, according to a survey by the American Society of Plastic Surgeons (ASPS), Buoyed by a concurrent surge in U.S. obesity surgeries, the number of abdominoplasties alone (also known as tummy tucks) has soared 22 percent in two years. Last year, U.S. plastic surgeons performed 1.8 million liposuctions, tummy tucks, eyelid surgeries, nose reshapings, breast augmentations and breast reductions.

It may be popular, but it isn’t cheap. Prices can vary widely, but according to one report, liposuction in the U.S. costs an average of $13,500. A breast augmentation costs about $8,000. A facelift about $15,000. For most of us, such prices are prohibitive. But it doesn’t take long on the Internet to discover that hope is not lost. Plastic surgeons in Brazil, Costa Rica, Argentina, Peru, Columbia, The Dominican Republic, South Africa, India and elsewhere offer the same procedures at a fraction of the price. Even with all the expenses of travel factored in, patients seeking cosmetic surgery in such countries typically pay at least 50 percent less than they would in the U.S.

Welcome to lipotravel, the growing trend of traveling to other countries for elective cosmetic surgery. Also known as lipo-tourism (a copyrighted phrase), surgical safaris and plastic surgery vacations, it is a subset of medical tourism, an increasingly popular approach to obtaining the medical care that grows ever further out of reach for the American uninsured. Both have spawned an entire industry of specialized travel agencies, concierges, facilitators, clinics and hospitals all jostling for patients and their money. The lipotravel business, with its assurances of easy beauty at cut-rate prices, genius surgeons, luxury accommodations, 24-hour hand-holding, the discretion of distance and the acceptance of Mastercard and VISA, seduces an estimated 100,000 Americans every year.

Those inclined to research also inform themselves by visiting the burgeoning number of websites, forums and chat groups on the subject. Although they typically start out interested in only one procedure, most lipotravelers decide -- since they’re going anyway and it’s so much cheaper -- to have two or more. When their experiences are good, like Anderson’s, they tend to be very good. But when their experiences are bad, like Schapiro’s, they leave physical and emotional scars much worse than the problem or problems they were meant to correct.

What makes the difference? There is no simple answer.

Experts recommend various precautions, but all surgery involves risk, and multiple surgeries involve more risk. And then there are factors individual to each patient. Age, for example. Blood pressure, medical history, obesity, diet and post-surgical care.

Air travel, both before and after surgery, also turns out to be a significant risk. According to a 2005 Mayo Clinic study of 181,765 post-surgical patients, those who traveled an average of 5,000 miles or more before surgery were over 30 times more likely to experience a life-threatening blood clot or pulmonary embolism within 28 days of surgery than those who did not.

In a related study, researchers found a link between post-surgical blood clots and the length of time patients spend under anesthesia. Add to that the skill of the particular surgeon, the frequency of complications unrelated to the skill of the particular surgeon and the emotionally-charged hopes and expectations of your elective cosmetic surgery average patient and the vagaries of fate and luck and all cosmetic surgery starts to look like a crapshoot no matter where it takes place.

Which is precisely why, according to its president, The American Society for Aesthetic Plastic Surgery (ASAPS) takes a somewhat dim view of lipotourism.

“Basically, the position of the society is, ‘Buyer beware,’” says Dr. Foad Nahai who practices plastic surgery in Atlanta.

“At least in this country, each state and the federal government have standards that we have to meet. All of them improve the chances for a good outcome.”

Even if you have a bad outcome in the U.S., notes Nahai, you can sue your surgeon, which is not necessarily the case in other countries. But compliance with government standards costs money. As does malpractice insurance.

“So the very reasons that make medical are safe in this country are the same reasons that make it expensive in this country,” he says. “And those same reasons are what makes it cheaper abroad.”

For those who cannot be dissuaded, “at least do your homework so you won’t have any surprises and you won’t get substandard care,” says Nahai. “We accept the fact that there are very good, well-qualified surgeons in every corner of the world. But there are perhaps just as many who are not.”

Doing your homework, as defined by ASAPS, means lining up a plastic surgeon at home to help you with potential complications and weighing the cost of potential post-travel complications and surgical revisions against the savings of having the surgery abroad. It also means knowing the answers to the following questions before you travel:

 

• What is the surgeon’s training? He or she should have specific training in cosmetic surgery procedures through an accredited plastic surgery residency program and/or fellowship. The International Society for Aesthetic Plastic Surgeons can provide some information.
• What happens if you develop complications? Who will care for you? And who will be financially responsible for secondary or revisional procedures?
• What is your legal recourse if you feel the surgeon has been negligent? What kind, if any, liability insurance does the surgeon hold? What are the local laws regarding medical malpractice?
• What are the standards of anesthesia and nursing care to which you will be subjected? Will your providers have the relevant credentials?
• Is there a fully modern and accredited acute-are hospital nearby in case of complications?
• Do key personnel in the surgeon’s office and the operating room speak and understand fluent English?
• What are the details of post-operative care and how much will it cost?

 

Not surprisingly perhaps, a number of these recommendations are difficult if not impossible to follow. Finding a plastic surgeon to deal with complications from cosmetic surgery abroad, for example, is notoriously difficult.

“No plastic surgeon will touch you,” says a 29-year-old Phoenix woman who tried to find one before traveling to the Rosenstock Lieberman Center for Cosmetic Plastic Surgery in Costa Rica for a breast lift, implants and liposuction last March. “I even looked for a general, primary care doctor, and I had to call about seven before I found one.”

As it turned out, she developed a hematoma in one of her breasts on the night before she was scheduled to fly home and had to stay and extra week. “If it had happened after I came back, it would have been a disaster,” she says.

Although widely viewed as evidence of greed, the reluctance of American plastic surgeons to treat the complications of foreign surgery actually arises from one specific fear, according to Nahai. “All of us have an ethical obligation to deal with a life threatening emergency,” he says. “But if someone comes in and says, ‘I had this done abroad and it doesn’t look right and I’m unhappy,’ the physician is under no obligation to that patient.” Under those circumstances, he says, “they may transfer their hostility to you because they have no legal recourse against the original surgeon.”

Barry Lycka, a Canadian plastic surgeon who founded The Ethical Cosmetic Surgery Association, is even less accommodating than the ASAPS when it comes to the topic of cosmetic surgery abroad. He’s against it. Period. Under all circumstances. “Plastic surgery is not a procedure, it is a process,” insists Lycka.

“You do something and then you wait and look to see how the result came out. And then, based on how the result cam out, you do something else. I often treat people with creams to prepare their skin for surgery and help them heal more quickly afterwards. Liposuction especially turns out much better with certain pretreatments. And then there are treatments afterwards that improve the results.

“My job isn’t over when the surgery is done. My job is over when the person has done well, healed and we can see the results of the surgery and those results are good.”

Lily Bates’ ideas about cosmetic surgery abroad were also once fairly negative. What she wanted was a tummy tuck in California. But after learning from a plastic surgeon there that the surgery would cost her $18,000, turned to the Internet. There she met a woman who had one in Baja, Mexico with good results.

“I dismissed it because it was Mexico,” Bates recalls. “And I had this idea that surgery in Mexico would be like some kind of back-alley abortion.”

But then she met another woman who had the same surgery with the same doctor and the same kind of results. “So I went there,” she says.

“And the place was nicer than most places here. It was a brand-new facility, the floors were marble, the offices were state-of-the art, everyone was wearing scrubs and behaving extremely professionally – I couldn’t believe how nice it was. And then they quoted me a price of $6,000, including an overnight stay, full body liposuction, muscle repair and a fat transfer into my butt. So I did it. And the results were just awesome.”

Bates was a convert. She returned home and, with her now husband, Marcel, started the web community, plasticsurgeryjourneys.com. In three years, the site has attracted 7,000 members who regularly exchange information about surgeons, countries and medical facilities, report on their experiences, post details of their surgeries and photos of their scars, discuss complications and generally support and reassure one another through often-grueling ordeals. Recently, a Mexico clinic that refused to refund a member’s money after he canceled his surgery was so deluged by e-mails and phone calls that it backed down.

“We look out for each other,” says Bates, known on the site as GirlyGirl. “When we all stick together, we, as patients, have power…We really are an army of researchers in each other’s service. If someone has a bad experience, 7,000 people hear about it and see the pictures. Our motto is, ‘All the good and all the bad of plastic surgery.’”

To that end, the site’s members zealously monitor it for interlopers with hidden agendas. “They’ll flag something like that immediately, and we’ll check it out,” says Marcel Bates. “That’s part of what makes us successful. A lot of these sites are sponsored by doctors and companies, but we want to be an unbiased advocate. This is a life and death thing people are doing, and if they have a bad outcome, we want to say so.”

As a result of the site, the Bates have extensive practical knowledge about both cosmetic surgery in general and the lipotourism landscape in particular. Breast implants and thigh surgeries seem to generate the most complications, Lily notices.. Facelifts the least. Although some of the best plastic surgeons in the world are in Brazil, the Brazilian standard of beauty does not include large breasts so people tend to go elsewhere for breast augmentations. Thailand is big for face and dental work, but few choose it for bodywork. Costa Rica dominates facelifts.

Their advice incorporates much of what the ASAPS has to say with the added distinction of being practical and to the point:

Consult three plastic surgeons in the U.S. before you decide to travel abroad. Don’t assume general surgical excellence from the results of just one procedure - a surgeon can be a genius at facelifts but terrible at tummy tucks. Don’t rely exclusively on the Internet. Use the phone. Call the facilities that interest you, past patients of surgeons you are considering and the boards by which those surgeons say they have been certified. Don’t go with the lowest bidder. Don’t choose a surgeon just because he or she is willing to do all the procedures you want because such willingness may indicate a lack of concern for your safety. Take as much time off to recover as possible. Get everything in writing. Pay attention and follow pre-op and post-op instructions. Walk away if it feels wrong.

This last point has special significance for Giovanna Goldfarb, a San Francisco woman who went to Argentina in 2006 for extensive dental work following a catastrophic fall. The dentists she consulted in San Francisco told her it would cost at least $80,000. But Plenitas, a plastic surgery clinic in Buenos Aires, said they could do the dental work plus eyelid surgery, a nose reshaping, a facelift, a tummy tuck and a breast lift with implants for $35,000, including lodging for 10 days. About to turn 50, recovering from both the fall and uterine cancer, Goldfarb went for it.

On her first day in Buenos Aires, a clinic assistant picked her up and took her to a hospital for medical tests. “It was a great big new gleaming hospital,” recalls Goldfarb.

“But when they tried to draw my blood, they didn’t even wear gloves. And then, after they filled the tubes, they just dumped the needles and the bloody gauze on the floor…I got a chest x-ray with no shielding. The next day, they took me to see this dentist in some crummy, run-down office, and he tells me he’s going to do bridges with no anesthesia. I’m like, ‘But I paid for crowns with anesthesia!’ I left and got into the car and I said, ‘This is not what I signed up for!” And the assistant starts arguing with me. He tells me the dentist says it’s not as serious a case as we thought. They had previously told me the head of the dentistry school at the University of Buenos Aires had looked at my x-rays. But in fact, they hadn’t shown them to anyone.”

That night, Goldfarb complained and the clinic agreed to take her to another dentist. But the second dentist was just as bad and Goldfarb walked out of her office. The clinic had her money so she underwent the breast augmentation.

“At no point did they ask me what kind of implants I wanted or how big,” she says. “They put in permanent sutures which are still there, embedded in my skin.”

Goldfarb developed a hematoma and had to undergo a second surgery to drain it. Instead of the planned-for 10 days, she was in Argentina for six months. She had five surgeries and, finally, the dental work. But by the time she got home, her nose had flattened and her teeth had begun to abscess.

The nose had to be reconstructed because the surgeon in Argentina had removed all the supporting cartilage. The crowns had to be removed and replaced because the dentist in Argentina did not seal them properly. Each tooth had to be drilled, cleaned out, refilled and sealed because of botched root canals and infection. So far, Goldfarb says, she has spent $62,000 fixing the problems she brought home from Argentina. And that doesn’t include two more surgeries she still needs on her mouth.

“If I had known I was going to be there for half a year, and if I had known what the results would be, they could have had the $35,000,” she says. “I would have run screaming.”

According to Jude O’Hara, Goldfarb’s story is not uncommon. O’Hara herself was both disfigured and restored by plastic surgeons in Buenos Aires, she says. As the result of those experiences, and in an effort to help others avoid the same fate, she and her partner, Phillip Hash, recently co-founded AestheticArgentina, a non-profit organization that refers cosmetic surgery patients to reputable and qualified surgeons free of charge, and raises money for restorative surgeries on children. When surgeons or clinics suggest multiple major surgeries in a relatively short time period, says O’Hara, watch out.

But just as the U.S. doesn’t have a monopoly on good plastic surgeons, foreign countries don’t have a monopoly on bad ones. Nor have they cornered the market on plastic surgery disasters. Some patients have bad results abroad. Some even die. But some patients have bad results here, too. And guess what? Some even die.

Among them were two women - one a famous novelist and one the wife of a Connecticut urologist – who died within two months of one another during cosmetic surgeries at the prestigious Manhattan Eye, Ear and Throat Hospital in 2004. Eight women died between 2002 and 2004 following cosmetic procedures in Florida. And last summer in Framingham, Ma., the death of one woman following liposuction and a nose job and the hospitalization of another led to the discovery of an underground cosmetic surgery mill and the arrest of a Brazilian doctor and his wife.

Because any U.S. physician can legally claim to be a specialist in any field regardless of training, it is wise to do your homework when seeking cosmetic surgery here as well. Doctors claiming to be “board certified” might not actually mean the American Board of Plastic Surgery, but some other board not recognized by the American Board of Medical Specialties (ABMS), an organization that sanctions only well-established and respected boards. It does not, for example, recognize “The American Board of Laser Surgery.” Or “The International Society of Cosmetic Laser Surgeons.”

Buyer beware, wherever you go.

--Laura LaFay’s work has appeared in numerous publications including the Washington Post.