Abstract
Background
The financial principles of a no-cost revision policy and their implications for revision rates are not well understood.
Objectives
Therefore, the primary objective of this retrospective study is to report our no-cost revision rates and, secondarily, to survey the cosmetic revision policies of other cosmetic surgery practices and detail the financial principles underpinning no-cost revisions.
Methods
All aesthetic surgeries and no-cost revisions performed by the plastic surgeons, oculoplastic surgeons, and facial plastic and reconstructive surgeons at our academic outpatient cosmetic surgery center from January 1, 2016 to June 30, 2022 were identified using procedural codes. Data on the number of surgeries, number of revisions, operative minutes, and time intervals between initial and revision surgeries were collected. A survey was administered to assess the revision policies of similar cosmetic surgery practices.
Results
A total of 1491 aesthetic surgeries and minimally invasive procedures were included, and 125 revision procedures were performed (8.4%). Thigh lifts (3, 13.6%), rhinoplasties or septoplasties (25, 15.8%), and otoplasties (3, 27.3%) had the highest revision rates. Three practices (15%) offered cosmetic revisions at no cost, 9 (45%) did not apply a surgeon's fee, 5 (25%) evaluated fees on a case-by-case basis, 1 (5%) offered revisions with an insurance policy, and 2 (10%) cosmetic surgery practices did not offer revisions at a reduced rate.
Conclusions
Despite offering revisions at no cost, our revision rates are reasonable for an academic cosmetic surgery practice. The revision policies offered to patients on the private market are varied, but most surveyed practices offer revisions at either a reduced rate or no cost.
Level of Evidence: 4
The University of Wisconsin-Madison expanded its academic cosmetic surgery program in 2006 by establishing a multidisciplinary cosmetic surgery center to capitalize on the growing demand for cosmetic care and expand cosmetic surgery exposure for medical students and residents.1 Faculty members from plastic surgery, otolaryngology, dermatology, ophthalmology, anesthesiology, and vascular surgery provide services at our academic cosmetic surgery practice.
Our physicians developed a no-cost cosmetic revision policy in collaboration with the administration. Since the institution owns the physical assets (facilities, surgical equipment, and supplies) and employs the physicians (cosmetic surgeons and anesthesiologists), we have been able to waive surgical fees, anesthesia fees, facility fees, and equipment/supply costs for revision procedures (Figure 1). This ownership structure has facilitated the implementation of no-cost revisions in our cosmetic surgery practice and when we provide cosmetic care, this policy has become a key component of preoperative counseling that allows us to cultivate goodwill with our patients.
Figure 1.
Cost considerations for implementing a no-cost revision policy.
There are 2 primary indications for cosmetic revision surgeries. The first indication is a postsurgical complication, such as a severe infection or hematoma, which may require intervention. However, the second indication, patient dissatisfaction, is a challenge unique to cosmetic surgery.2 Patient dissatisfaction requires the surgeon and patient to jointly identify the concern, agree that surgical intervention can improve the outcome, and be willing to pursue surgery. Even when the surgeon and patient agree to proceed with surgery, the prospect of surgeon's fees, anesthesia fees, operating room fees, other facility fees, and time investment may be obstacles to providing the surgery. However, a no-cost revision policy is a practical solution to help patients overcome these challenges.
At first glance, a no-cost revision policy may seem exceedingly generous to the patient and financially detrimental to the surgeon. However, it is important to consider opportunity cost, an increasingly popular economic topic in surgical research.3–8 Defined in plain terms, opportunity cost is the potential gain or loss when a person chooses to perform an activity over its next best alternative. In the context of reoperation, the next best alternatives are either a revenue-generating surgery, clinic visits, or the often-forgotten comparator—doing nothing. Choosing 1 of these 3 options requires the operating surgeon to risk both patient dissatisfaction and their reputation in the highly competitive, cosmetic surgery market. A no-cost revision policy considers an entirely different opportunity cost—the downstream impact of patient satisfaction.
Despite the variation in the revision policies offered by cosmetic surgery practices and nuanced considerations in structuring cosmetic revision policies, the implications of these policies and the effect they may have on revision rates are not well understood. Thus, the primary objective of this study is to report our no-cost revision rates, and secondarily, to compare our no-cost revision policy with similar cosmetic surgery practices, present the cosmetic surgery revision fee structures offered on the private market, and discuss the financial principles underpinning no-cost revisions.
METHODS
Data Collection
This retrospective study included all aesthetic surgeries performed by the plastic surgeons, oculoplastic surgeons, and facial plastic surgeons at our academic cosmetic surgery center from January 1, 2016 to June 30, 2022. These surgeries were performed by faculty members and were not part of a resident clinic. A total of 1491 aesthetic surgical procedures and their revisions were identified using procedural codes (Supplemental Table). All recorded revisions were performed due to cosmetic dissatisfaction. The data repository team extracted the operative minutes and the time interval between initial and revision surgeries. The study did not assess individual patients or protected health information; therefore, the study was exempt from Institutional Review Board approval.
Survey of No-Cost Aesthetic Surgery Revision Policies
A dichotomous survey (Yes or No) (Appendix) was administered to all cosmetic surgery practices that were similar to our practice and had contacts with the business division of our institution. The surveys assessed whether each respondent applied surgeon fees for aesthetic revisions, applied anesthesia or facility fees for aesthetic revisions, whether the fees depended on the operation, and whether the organization charged zero fees for aesthetic revisions. If applicable, time limits to request a no-cost revision were reported.
Statistical Analysis
Categorical data are described as frequencies and percentages. Non-normally distributed data are described as medians and interquartile ranges.
RESULTS
The total number of aesthetic surgeries and procedures was 1491 and of these surgeries, a total of 125 were revised (8.4%). Thigh lifts (N = 3, 13.6%), rhinoplasties or septoplasties (25, 15.8%), and otoplasties (3, 27.3%) had the highest revision rates. Breast implant removals had the lowest revision rates (3, 2.34%; Figure 2).
Figure 2.
An academic cosmetic surgery practice's no-cost revision rates.
The no-cost revisions with the longest procedure lengths were thigh lifts (194 min), followed by facelifts (128.5 min), mastopexies (115 min), and breast augmentations (102.5 min). Otoplasties had the shortest revision procedure length (52 min). The procedure with the greatest time interval between initial and revision surgeries was breast reductions (440 days), followed by abdominoplasties (355 days) and otoplasties (289 days). The procedure with the shortest time interval between initial surgery and revision was breast implant removal (69 days; Table 1).
Table 1.
No-Cost Revision Surgeries: Operative Minutes and Days After Initial Surgery
| Procedure type | Operative minutes (IQR) | Days between initial and revision surgeries (IQR) |
|---|---|---|
| Abdominoplasty | 94 (74.75-164.25) | 355 (243-569) |
| Blepharoplasty | 80 (45.75-114.75) | 193 (139-375) |
| Breast augmentation | 102.5 (69.75-130.75) | 197 (160-307) |
| Breast implant removal | 82 (72.5-105.5) | 69 (49-176) |
| Breast reduction | 98 (76-182.5) | 440 (277-484) |
| Facelift | 128.5 (63.5-134) | 330 (22-359) |
| Liposuction | 68 (62-87.5) | 275 (245-327) |
| Mastopexy | 115 (95-163.25) | 193 (136-306) |
| Otoplasty | 52 (51.5-71.5) | 289 (243-495) |
| Septorhinoplasty | 71 (41-88) | 315 (245-449) |
| Thigh lift | 194 (149.5-214.5) | 191 (116-336) |
Brachioplasty, brow lifts, and fat transfers were excluded due to low sample size (N < 3). IQR, interquartile range.
A total of 20 (80%) cosmetic surgery practices responded to our survey. The majority (85%) of practices were private, while only 3 (15%) were part of a healthcare organization. If applicable, practices reported 90 days (n = 1), 6 months (n = 3), 1 year (n = 4), and 2 years (n = 1) as time limits for patients to request revision procedures. A majority of practices charged anesthesia and facility fees (n = 11, 55%) for revision procedures. However, of the subset that charged for anesthesia and facility fees with a revision policy, a majority (n = 9, 81.8%) did not charge a surgeon's fee, with 2 facilities stating that the surgeon's fee was evaluated on a case-by-case basis. Three practices (15%) indicated surgeon, anesthesia, and facility fees were evaluated on a case-by-case basis. Overall, 3 practices performed no-cost aesthetic revision surgery (15%). One practice covered revisions using cosmetic surgery insurance and 2 practices did not cover revisions (Table 2).
Table 2.
Aesthetic Surgery No-Cost Revision Policies at Affiliated Practices
| Revision policy | N (%) |
|---|---|
| Revision at no cost | 3 (15.0) |
| Surgeon's fee (no), A/F fee (yes) | 9 (45.0) |
| Surgeon's fee (depends), A/F fee (yes) | 2 (10.0) |
| Both surgeon's and A/F fees depend | 3 (15.0) |
| Covering with insurance | 1 (5.0) |
| Not covering | 2 (10.0) |
| Total | 20 (100) |
No = fee is not charged at the time of revision; yes = fee is charged at the time of revision; depends = surgeon determines the fees applied on a case by case basis. A/F, anesthesia and/or facility fees.
DISCUSSION
This retrospective analysis of our institution's experience with a no-cost revision policy revealed that our most common no-cost cosmetic revision procedures were thigh lifts, septoplasties or rhinoplasties, or otoplasties. Further, among the surveyed respondents, we found that only 3 (15%) other cosmetic surgery practices offered no-cost revisions to their patients, while fee structures varied widely for other practices. Herein, we discuss the implications of our revision rates, the varied revision fee structures available to physicians practicing cosmetic surgery, and discuss the financial implications of these policies.
No-Cost Revision Rates
Our overall revision rate was 8.4% and the 3 most common no-cost revision procedures were thigh lifts, septoplasties or rhinoplasties, and otoplasties. Although our otoplasty revision rate of 27.3% is higher than the rates reported in the literature,9,10 this comparison is limited by our smaller sample size of eleven otoplasties. In contrast, our breast augmentation and rhinoseptoplasty revision rates of 11.6% and 15.8% are comparable to reported reoperation rates ranging from 9.9%-28.3% and 11%-23.9%, respectively.11–16 We also had revision rates comparable to or lower than those reported in the literature for thigh lifts (13.6%),17 mastopexies (12.6%),18,19 abdominoplasties (8.8%),20,21 blepharoplasties (8.5%),22 facelifts (6.5%),23 and breast reduction (4.8%).24,25 Despite offering revisions at no cost, eliminating this cost barrier does not appear to manifest a notable increase in the number of revisions provided to patients. Thus, in the context of surgical literature, our revision rates suggest that a no-cost revision policy may not result in a substantial increase in revision surgeries and offer the added benefit of providing reassurance to prospective patients.
No-Cost Revision Policies
Our survey of other cosmetic surgery practices revealed that the most common fee structure is to charge anesthesia and facility fees but not charge the surgeon's fee when offering cosmetic revisions. This may be due to the payment structure established between anesthesia services and ambulatory surgery centers (ASCs). Most ASCs (70%) contract with anesthesia groups without a salary, and these anesthesia groups receive all professional fees.1 Therefore, the renegotiation of contracts with anesthesiologists may allow practices to offer no-cost revision policies. In this negotiation, it is important for the cosmetic surgeon to emphasize the underlying expectation that some number of patients will require revisions in the cosmetic cases they bring to the anesthesia team, which should be accounted for as the cost of doing business in cosmetic surgery.
Our institution's current revision policy is structured around a 1-year time limit for the operating surgeon and patient to recognize that the cosmetic outcome is not optimal and agree that surgery may improve that outcome (Table 3). In most cases, no-cost revision will be offered to patients whose desired primary outcome was not achieved. Due to high scheduling demand, it is often the case that the surgeon will agree to a no-cost revision within the 1-year time frame but schedule the no-cost revision at a much later date. Importantly, no-cost revisions do not apply to cases in which the patient's desired changes revolve around changing the originally agreed upon procedure (ie, would like a different breast implant size). An exception to the 1-year time limit is rhinoplasty, where 2 years are allotted for assessment and revision of original surgery. For all other revisions >1 year, but <2 years, surgeon's fees are waived, while facility and anesthesia fees are applied. Our program does not require patients to purchase a cosmetic surgery insurance policy and is “self-insured” for the complications of cosmetic surgery. Further, the fees for the cosmetic surgery program are set based on market conditions, and the no-cost revision policy was not a factor in setting the fees. However, when patients are referred to us for revision of another physician's work whose practice is outside of our institution, the standard fees are applied.
Table 3.
Our Single Institution's No-Cost Cosmetic Revision Policy
| Type of policy | Description |
|---|---|
| No-cost revision |
|
| Revision requests outside of the qualifying timeframe |
|
| Nonqualifying events |
|
In comparison, only 15% of practices provide no-cost revisions. Interestingly, this policy is most common in healthcare organizations (our institution and 2 other practices), while only 1 private practice provides revision surgery at no cost. We attribute the ability to offer no-cost revisions to the compensation model of large healthcare organizations which contrasts with a traditional private practice model where revenue directly impacts income. Today, strictly collection-based compensation plans are less common in healthcare organizations. Rather, many organizations offer a hybrid compensation plan with a combination of collections, services billed, or base salary that is coupled with productivity bonuses. As a result, time spent in performing no-cost revisions does not directly impact the compensation of the provider.
The policies of other practices demonstrate the importance of reducing costs for patients to optimize patient care; 60% indicated no surgeon fee would be applied to revisions, while another 30% would consider no-cost revision on a case-by-case basis or cover revision using cosmetic insurance. Only 10% of practices do not offer reduced or no-cost revisions. These reduced or no-cost policies reflect the importance of optimizing patient satisfaction in a competitive private market. Discussion of revision policies preoperatively allows the surgeon to proactively manage expectations and should be considered part of the preoperative assessment for surgery.26 Should the patient request a no-cost cosmetic revision when the surgeon disagrees that a revision is required, it is critical for the surgeon to articulate the considerable risks of revision surgery and emphasize that it may not yield the patient's desired results.
Opportunity Cost
In the field of plastic surgery, clinical productivity hinges on the ability of the surgeon to perform surgery efficiently. As a result, there is a strong motivation to assess opportunity cost in order to increase efficiency to maximize revenue.3,27 Thus, time spent performing a no-cost revision may be benchmarked against the next best alternative—performing an additional surgery at full cost.
Healthcare administrators may argue that no-cost revisions are worth the retail fee of a procedure multiplied by the number of procedures performed, and further, surgeons may even argue that their practice is too busy to provide services at no cost. There are material costs, such as the medications, suture materials, and dressing supplies used in the revision operation. However, assessing revisions based on the retail fee of a given procedure or the time investment alone is an oversimplification. One must consider the downstream effects of foregoing revision surgery, especially when the patient cannot afford or is unwilling to pay for revision. A patient who is dissatisfied with their surgery may leave negative reviews online, which can be difficult to remove or address.28 Some patients may even file lawsuits, adding further cost and time away from clinical practice.29 Therefore, while the immediate opportunity cost of performing no-cost revision surgery might appear to favor revenue-producing surgery, one must account for the added risk of downstream consequences of foregoing revision (Figure 3). On the other hand, a surgeon who offers no-cost revisions has an additional tool to optimize their reputation in the marketplace and cultivate goodwill with patients by helping the patient overcome their dissatisfaction, which can help prevent the loss of patients to other surgeons in competitive markets.
Figure 3.
Potential downstream effects of foregoing no-cost revisions.
The results of this study should be interpreted in light of its limitations. First, we report no-cost revision policies from a limited number of cosmetic surgery practices, which may not be representative of all revision policies present across the country and may be subject to bias, as these practices have relationships with our institution. Second, we report revision rates of procedures performed by multiple surgeons using varied surgical techniques, which may limit the comparison of our rates to studies examining revision rates for a specific surgical technique. Third, we do not offer case–control data on patient satisfaction to demonstrate that a no-cost revision policy significantly increases patient satisfaction. However, we do believe that explaining to patients that revisions will be covered at no cost would only serve to bolster patient satisfaction. Fourth, given that our data were extracted from a de-identified data repository, we were unable to determine if patients underwent multiple revisions. However, given that this is a rare event in our clinical practice, we anticipate that including this data would have little or no impact on our data analysis. Lastly, we did not have access to the fees that other practices charged, nor do we have cost information for our revision procedures given that the true cost is the materials used (ie, medications and suture material, we have not used materials such as dermal matrices). This should be a consideration for future investigations on no-cost aesthetic revision policies.
CONCLUSIONS
Despite offering revisions at no cost, our revision rates are reasonable for an academic cosmetic surgery practice. Our no-cost revision policy has helped us build and enhance our academic cosmetic practice at minimal cost. The revision policies offered to patients on the marketplace are varied, but most surveyed practices offer revisions at either a reduced rate or no cost.
Supplementary Material
Supplemental Material
This article contains supplemental material located online at www.asjopenforum.com.
Disclosures
The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.
Funding
The authors received no financial support for the research, authorship, and publication of this article, including payment of the article processing charge.
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