Messaging Safety as a Value in Patient Choice

Social media algorithms, photograph filters, and humanity’s pursuit of perfection have led to continued growth in aesthetic procedures each year, including a growing number of adolescent patients. Additionally, the global pandemic precipitated a “Zoom boom” of new patients exacerbating the already dramatic increase in outpatient cosmetic procedures.¹

Responsible board-certified plastic surgeons have always played an essential role in setting realistic expectations and ensuring the psychological stability of patients before undertaking surgery or other aesthetic procedures. They may also turn away prospective patients because of unsafe requests (including unreasonable surgical combinations or surgical durations), pre-existing conditions, or complicating comorbidities that may cause adverse events or death.

Safety of Cosmetic Procedures in Accredited Office-Based Surgery Facilities

Data from the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) and the CosmetAssure (Birmingham, AL) databases of cosmetic procedures show that accredited office-based surgery (OBS) facilities are a safe alternative to ambulatory surgery centers (ASCs) and hospitals for board-certified plastic surgeons to conduct virtually all single, combined, and even complex cosmetic procedures.^2,3 In fact, there was a significantly lower risk of developing a complication in an OBS setting compared with an ASC or hospital from any cosmetic procedure.³ Further, a recent review of >350,000 abdominoplasties confirmed earlier reports that even when combined with other procedures the incidence of venous thromboembolism (VTE)—one of the most serious complications in cosmetic surgery—is very low when performed in accredited OBS facilities by board-certified surgeons.^4,5 Although a higher incidence of VTE during abdominoplasties, when combined with other procedures, has been reported,⁶ this finding is not universal.^4,7 An important reason for differences in VTE incidence reporting rates in some databases may reflect differences in the denominator.⁵ Safety in older patients (>65 years of age) undergoing cosmetic procedures in accredited OBS facilities with board-certified plastic surgeons is also well established as being similar to that of younger patients.^8,9

Although the advantages of outpatient surgery are clear for the patient and staff, there are still legitimate concerns about deaths that occur after ambulatory surgery.¹ Whereas there is ample patient and procedure safety data from AAAASF’s Patient Safety Data Reporting (PSDR) and the CosmetAssure databases documenting the excellent safety of cosmetic surgical procedures performed in accredited OBS facilities by board-certified surgeons, there are no comparative data or centralized data collection from non–board-certified cosmetic surgeons operating in facilities with no accreditation oversight. This results in only being able to compare AAAASF-accredited facility data to data collected in the CosmetAssure database. Alternatively, researchers can compare AAAASF and CosmetAssure data together against the hospital or ASC, leaving researchers, regulators, and patients to guess as to how the data compare to the completely unknown world of offices outside of these systems. Thus, the data refer only to American Board of Plastic Surgery (ABPS)-certified plastic surgeons and to American Society of Plastic Surgeons (ASPS) candidates for membership and patient populations already being treated in the safest OBS facilities.^3-5 There is no comparator for the non–AAAASF-accredited, non–board-certified population that sometimes make headlines for tragic outcomes that negatively impact the entire aesthetic surgery world.

When patients are turned down or advised to spread treatments over time for safety by responsible doctors, it is folly to assume that they routinely accept this guidance. At least some seek a provider willing to do what the patient asks. If patients are turned down by plastic surgeons in accredited OBSs who triage their patients carefully based on their best judgment and possible comorbidities, where are they going?

Because aesthetic surgery is typically not physician referred or covered by insurance, patients find practices independently. Patients base their decisions on “consumer” reviews without knowing how to choose a safe option or its importance.³ Others base their choices on practitioner charisma, fancy websites, engaging social media, and the promise of low prices. Some marketing tactics emphasize “less invasive,” “minimally invasive,” or “noninvasive” aesthetic procedures, suggesting that these procedures carry no or minimal risks. This leads to patients who no longer treat procedures with the sobriety consistent with medical care; instead, they focus on convenience, cost, and whether the doctor will meet their demands. A quick Google search for “cheap cosmetic surgeons near me” may provide insight.

Headlines such as “Breast Augmentation: A Great Valentine’s Day Gift,” “Celebrity Cosmetic Surgeon’s Liposuction Patient in ICU After ‘Major’ Blood Loss,” and “Unlicensed Houston Woman Accused of Performing Deadly Cosmetic Procedure” demonstrate the draw and consequences of this all-too-familiar phenomenon; patients are unequipped to make the safest choices when it comes to their surgery. The technical points are dizzyingly confusing. As a result, they book appointments with “specialists” in cosmetic surgery or aesthetics; while we differentiate easily between plastic surgeons and cosmetic and aesthetic surgery, the public often cannot. Patients have little or no understanding of the difference between a non–board-certified “plastic surgeon” and one who is board-certified. Nor do they understand that some physicians claiming to be experts in cosmetic or aesthetic surgery could be board-certified in an unrelated specialty, and not have the requisite training or credentials to provide for patient safety in a surgical setting. Adding to the confusion are the proliferation of boards that do not require the same exacting criteria as American Board of Medical Specialties (ABMS) and American Osteopathic Association/Bureau of Osteopathic Specialists (AOABOS) boards, but nonetheless style themselves to convince patients of their purported safety.

How Do We Keep Cosmetic Surgery Patients Safe?

The logical answer is educating and empowering patients to make better and safer choices, which is easier said than done. It starts by ensuring board-certified plastic surgeons remain vigilant in offering the safest possible care in accredited facilities. In the 1980s and again in 2015 amid the gluteal fat transfer deaths, the Aesthetic Surgery Education and Research Foundation formed task forces to study mortality and complication rates. Systematic physician campaigns resulted in higher patient safety standards and fewer complications.¹⁰ The mandates by both US plastic surgery societies, ASPS and The Aesthetic Society, for plastic surgeons to work in licensed or accredited facilities in 1998 represented a significant step forward.

Accreditation organizations update standards to ensure the highest safety precautions before, during, and after a procedure and to guarantee the necessary emergency provisions are in place should an adverse event occur. These efforts are mostly underappreciated by the public because they do not know these standards exist or how to find practitioners who adhere to them. In 2021 research on patient decision-making, AAAASF found that the top patient concerns pertain to worry that something might go wrong in a procedure due to quality of care, infection control, or environmental cleanliness, and that centers might not be prepared to handle emergencies. Patients also showed that they are not qualified to assess facility safety because they deem a provider merely having a medical degree as being one of the most significant determinants of safety with no appreciation for specialty training. Thus, safety is an important concern to patients, but they lack the tools to assess a physician or practice.

Additionally, although many patients would like to assume accreditation is universally required, only 27 US states have accreditation language on the books. Patients need digestible education about accreditation and how to check a facility’s accreditation status. To bridge this huge gap in patient understanding of surgical safety, AAAASF is launching a patient safety education campaign to inform the public and primary care physicians about the importance of choosing an accredited facility. We need to be more explicit and direct in our messaging, not just in the office, emphasizing that a board-certified plastic surgeon at an accredited facility is the safest way to undergo a procedure. AAAASF accreditation is the gold standard; patients should know that. We as a community cannot leave these concerns unsaid and cannot assume that patients understand the implications behind your board certification, your accreditation certificate, and your guidance for their safety on the one hand, and the absence of these things in another office or center. AAAASF’s Patient Safety Data Reporting statistics support the safety of this model, as demonstrated through articles written by research partners at Harvard and elsewhere. It is critical for individual plastic surgeons and centers to reinforce this message proactively and in individual patient interactions, so patients will begin to contemplate the real trade-offs they make when they go to an unaccredited office or seek care from a non-boarded physician.

Accreditation and Board Certification: A “Must-Have” for Patient Safety

There is evidence showing that accreditation verification can serve as a more powerful recommendation source than one from a friend or family member because many patients already understand that accreditation is synonymous with legitimacy and quality.¹¹ It is up to us collectively to ensure patients understand accreditation is a “must-have” and not a luxury. Equally important, because patient safety knows no borders, AAAASF has led an effort to standardize patient safety globally through a collaboration with the International Society of Plastic Surgery (ISAPS).

When it comes to plastic surgery, it is also crucial to explain the importance of physician board certification. ABMS and AOABOS board-certified plastic surgeons are the most highly trained in aesthetic surgery, and accredited facilities ensure the highest levels of safety. If an adverse event happens, accredited facilities are equipped and have procedures to handle it.¹¹ Patients also want to know that the facility chosen will provide quality care through capable nurses, technicians, and administrative staff in addition to the physicians. Choosing a plastic surgeon who is a member of ASPS or The Aesthetic Society (or internationally ISAPS) reduces potential confusion because these organizations ensure their members have the appropriate board certification, training, and require the physicians to practice in an accredited facility. It is incumbent upon the entire specialty to develop coherent messaging to communicate these finer points explicitly and clearly to the entire patient population.

Get Accredited and Educate Your Potential Patients

We ask that you, the board-certified plastic surgeon, do your part to help combat a race to the bottom in aesthetic surgery. First, if your center is not accredited, get accredited. Second, speak directly to your patients about the value to them of choosing an ABMS or AOABOS board-certified physician working in an accredited facility and why you are making recommendations about their care, the dangers that could arise from deviating from those recommendations, or why they may not be a good candidate for certain procedures. It is also important to help patients understand the difference between ABMS or AOABOS board-certification and cosmetic surgeons claiming to be board-certified. We also highly recommend that you add simple accreditation messaging to your website, patient communications, and during interviews, promotional, and educational sessions to drive the message home. AAAASF is committed to patient safety and to helping elevate your practice profile. We are also committed to providing patient education to help the public appreciate the protective measures you follow. Together we can empower our patients to make the best choice for their aesthetic and plastic surgery procedures.

Disclosures

Dr Rosenblatt is an officer of the AAAASF. Mr Terranova has no conflict of interest to disclose.

Funding

Dr Rosenblatt is an officer of the AAAASF and receives an annual stipend in that capacity. Mr Terranova has no funding information to disclose.