Managed care's attempts to capture aesthetic surgery

Managed care organizations recently have attempted to add aesthetic surgery to their line of available services. To better understand the challenges posed by these actions, all members of the American Society for Aesthetic Plastic Surgery were surveyed about managed care overtures to aesthetic plastic surgeons, their responses, and the likely responses of their patients. The goal was to examine both the supplier and consumer ends of the aesthetic surgery market to determine the likely effects of managed care's attempts to capture aesthetic surgery. A total of 632 plastic surgeons returned the surveys (response rate, 54.5 percent). Twenty-two percent reported being approached by managed care organizations about joining a panel of aesthetic surgeons. Approximately one-quarter of the plastic surgeons said they would participate in aesthetic surgery panels developed by managed care organizations. Characteristics significantly associated with willingness to participate were solo practice structure, a low percentage of practice revenues from aesthetic surgery, and a very competitive practice environment. Plastic surgeons believed that their colleagues would be even more willing to acquiesce to managed care aesthetic surgery; more than one-third said that 25 to 50 percent of their colleagues would join, and nearly one-third thought that more than half would participate. Plastic surgeons believed that many of their patients would also participate in managed care aesthetic surgery. Twenty-four percent thought that more than half of their patients would choose an aesthetic surgeon through their managed care organization if that organization developed a network for aesthetic surgery. This figure increased to almost 40 percent if the organization would deny coverage for complications resulting from nonpanel surgeons, and to 41 percent if the organization would offer price discounts. This survey shows that most plastic surgeons are against managed care aesthetic surgery. But it also shows that some plastic surgeons will participate, and that most plastic surgeons think many of their colleagues and patients will do likewise. This means that managed care organizations have the potential to make inroads in aesthetic surgery on both the supplier and consumer ends of the market. To prevent managed care from capturing aesthetic surgery, plastic surgeons must anticipate the likely business strategy of managed care. To this end, they must understand the steps involved in the creation of a new service business and offer organized countermeasures against each of them.     

Impact of the journal Plastic and Reconstructive Surgery.

The "impact" of Plastic and Reconstructive Surgery was evaluated by bibliometric analysis. This technique considers the average frequency with which journal authors refer to articles published in Plastic and Reconstructive Surgery. The impact of Plastic and Reconstructive Surgery was compared with that of journals most commonly referred to within Plastic and Reconstructive Surgery as well as with that of journals read most commonly by Plastic and Reconstructive Surgery subscribers, such as the Annals of Plastic Surgery and the Journal of Hand Surgery (both American and British editions). The impact factor for Plastic and Reconstructive Surgery was at least twice as great as for any other journal related to this surgical subspecialty. With regard to other surgical subspecialties, while the impact factor for Plastic and Reconstructive Surgery was less than that of the Journal of Neurosurgery, Journal of Urology, and Journal of Ophthalmology, it was greater than those for orthopedics, otolaryngology, hand surgery, and dermatologic surgery.     

A new educational role for plastic surgery in the fourth year of medical school

At most medical schools, students are offered limited or sporadic experiences in plastic surgery. This is unfortunate because all physicians need to possess the knowledge and skills to evaluate skin lesions and participate in wound management. Also, students who are considering a career in plastic surgery do not have adequate information to make informed decisions. With the restructuring of plastic surgery training programs, career decisions of individuals interested in plastic surgery are being made earlier than ever before in the education continuum, and the aforementioned problem assumes greater magnitude both for the students and the faculty. At MCP-Hahnemann School of Medicine, basic plastic surgery experiences have been integrated into the third-year surgery clerkship as a requirement for all students, and a Plastic Surgery Pathway has been designed in conjunction with the school's pathway system for fourth-year students. The Pathway provides a framework for the student to select a combination of rotations that will best provide an appropriate broad-based education in preparation for training in plastic surgery, and it provides extensive guidance by faculty members in the discipline to assist with career decisions, rotation selection, and preparations for the residency application process. Students in the Plastic Surgery Pathway are required to take rotations in medicine, neurology, and plastic surgery. The remaining rotations are selected from a list of options based on the student's individual learning needs, interests, and career aspirations. Early experience with the Plastic Surgery Pathway has shown that it has been well received by students and faculty, has assisted students with their career decisions, and has led to an increased student awareness of the importance and relevance of the specialty.     

The financial environment of aesthetic surgery: results of a survey of plastic surgeons

To gather information about aesthetic surgery's current practice structures, competitive environment, patient price sensitivity, and marketing and practice development requirements, a two-page survey was developed and mailed to all 1180 members of the American Society for Aesthetic Plastic Surgery. A total of 632 surveys were returned (response rate of 54.5 percent). Most aesthetic plastic surgeons said they were in solo practice (63.3 percent). More than two-thirds described the marketplace as "very competitive," with 59 percent reporting 25 or more surgeons offering aesthetic surgery in their area. They estimated their patients' average income at $62,800. Nearly all plastic surgeons labeled their patients as "moderately price sensitive" (62.3 percent) or "very price sensitive" (30.6 percent). Similarly, 23.2 percent estimated that they had lost 20 or more patients within the last year for reasons of price. Practice development and marketing efforts represented an average of 7.3 percent of plastic surgeons' working time. Parameters associated with a high percentage of time devoted to these activities were solo practice, percentage of revenue from aesthetic surgery greater than 50 percent, a practice environment designation of moderately or very competitive, and ten or more area surgeons offering aesthetic surgery (p < 0.05). High patient income led to only slight decreases in price sensitivity and did not significantly reduce the amount of time spent on marketing and practice development. Although the rest of the healthcare industry has undergone a period of consolidation, aesthetic surgeons have been able to resist these changes. The results of this survey suggest that the fragmented nature of the aesthetic surgery industry is associated with additional burdens on plastic surgeons. As the aesthetic surgery market becomes more competitive, plastic surgeons may benefit from consolidation to reduce costs and maximize efficiency.     

医疗美容医疗纠纷成因分析及对策探讨

医疗美容科是外科手术较为频繁、患者对手术期望极高的科室。患者所要求的不仅仅是安全,而且对术后效果更为重视,整形美容科术后效果不佳是整形美容科医疗纠纷高发的重要原因之一。通过对整形美容医疗纠纷成因进行分析,消除医疗事故隐患,规避医疗风险。     

National plastic surgery survey: face lift techniques and complications

The purpose of this study was to assess trends in technique and philosophy of face lifting, associated procedures, and the incidence and management of complications. Surveys were sent to 3800 members of the American Society of Plastic and Reconstructive Surgeons (ASPRS); 570 surveys (15 percent) were returned. Numerous very specific technique and philosophy questions were asked. Details of demographics, techniques, incidence of complications, management of complications, and basic philosophy are presented. Three basic conclusions can be gleaned from this study: (1) Surgeons perform more tried and true methods of aesthetic surgery, rather than the many new methods that seem to get the most attention in the media and at the meetings. (2) It seems that less-experienced surgeons tend to be generally more conservative in their approach to aesthetic surgery. (3) Complication rates reported by the plastic surgery community at large coincide with previous complication rates, as outlined in other nonsurvey studies. The authors expect to report additional data from the survey--on brow surgery (part II) and facility and ancillary procedures (part III)--in forthcoming publications.     

The Danish Registry for Plastic Surgery of the Breast: establishment of a nationwide registry for prospective follow-up,quality assessment,and investigation of breast surgery

Although numerous epidemiologic studies have examined the long-term safety of silicone breast implants during the past decade, there is a relative lack of surveillance data on short-term health effects and complications following cosmetic surgery of the breast. The Danish Registry for Plastic Surgery of the Breast, established in May of 1999, provides plastic surgeons with a nationwide system for the collection of preoperative, perioperative, and postoperative data on women undergoing breast implantation, breast reduction, or mastopexy. The purpose of the Registry is to examine short-term and, eventually, long-term local complications and possible health effects, and to contribute to an ongoing evaluation of surgical results and surveillance of the products. Furthermore, the Registry will allow the identification of new areas for research into cosmetic and reconstructive breast surgery. Women accepting registration in the Danish Registry for Plastic Surgery of the Breast complete a self-administered questionnaire focusing on medical history and demographic and behavioral factors. Preoperative blood samples are drawn for storage. Surgical data, postoperative results, and complications are registered following surgery and at postoperative visits. Currently, registration has been initiated at 24 private and public clinics, representing more than 80 percent of the plastic surgery clinics in Denmark. As of November of 2001, a total of 1472 women with breast implants and 560 women with breast reduction were included in the Registry. These figures are expected to increase annually by 1000 women undergoing breast implantation and 500 women undergoing breast reduction or mastopexy. The authors present their experience of establishing the first nationwide comprehensive clinical-epidemiologic database and biological bank for cosmetic and reconstructive surgery procedures.     

The economics of plastic surgery practices: trends in income, procedure mix, and volume

Anecdotally, plastic surgeons have complained of working harder for the same or less income in recent years. They also complain of falling fees for reconstructive surgery and increasing competition for cosmetic surgery. This study examined these notions using the best available data. To gain a better understanding of the current plastic surgery market, plastic surgeon incomes, fees, volume, and relative mix of cosmetic and reconstructive surgery were analyzed between the years 1992 and 2002. To gain a broader perspective, plastic surgeon income trends were then compared with those of other medical specialties and of nonmedical professions. The data show that in real dollars, plastic surgeon incomes have remained essentially steady in recent years, despite plastic surgeons increasing their surgery load by an average of 41 percent over the past 10 years. The overall income trend is similar to that of members of other medical specialties and other nonmedical professionals. The average practice percentage of cosmetic surgery was calculated and found to have increased from 27 percent in 1992 to 58 percent in 2002. This most likely can be explained by the findings that real dollar fees collected for cosmetic surgery have decreased very slightly, whereas those for reconstructive procedures have experienced sharp declines. This study demonstrates that plastic surgeons have adjusted their practice profiles in recent years. They have increased their case loads and shifted their practices toward cosmetic surgery, most likely with the goal of maintaining their incomes. The strategy appears to have been successful in the short term. However, with increasing competition and falling prices for cosmetic surgery, it may represent a temporary bulwark for plastic surgeon incomes unless other steps are taken.     

Measuring co-authorship and networking-adjusted scientific impact

Appraisal of the scientific impact of researchers, teams and institutions with productivity and citation metrics has major repercussions. Funding and promotion of individuals and survival of teams and institutions depend on publications and citations. In this competitive environment, the number of authors per paper is increasing and apparently some co-authors don't satisfy authorship criteria. Listing of individual contributions is still sporadic and also open to manipulation. Metrics are needed to measure the networking intensity for a single scientist or group of scientists accounting for patterns of co-authorship. Here, I define I(1) for a single scientist as the number of authors who appear in at least I(1) papers of the specific scientist. For a group of scientists or institution, I(n) is defined as the number of authors who appear in at least I(n) papers that bear the affiliation of the group or institution. I(1) depends on the number of papers authored N(p). The power exponent R of the relationship between I(1) and N(p) categorizes scientists as solitary (R>2.5), nuclear (R = 2.25-2.5), networked (R = 2-2.25), extensively networked (R = 1.75-2) or collaborators (R<1.75). R may be used to adjust for co-authorship networking the citation impact of a scientist. I(n) similarly provides a simple measure of the effective networking size to adjust the citation impact of groups or institutions. Empirical data are provided for single scientists and institutions for the proposed metrics. Cautious adoption of adjustments for co-authorship and networking in scientific appraisals may offer incentives for more accountable co-authorship behaviour in published articles.     

Planning elective operations on patients who smoke: survey of North American plastic surgeons.

Patient smoking status affects many aspects of plastic surgery, including patient selection, counseling, management, and outcomes. No specific recommendations for performing elective procedures on patients who smoke are available. The goal of this study was to determine the current practice standards and attitudes toward this often controversial topic. In September of 2000, 1600 members of the American Society for Aesthetic Plastic Surgery were sent questionnaires, 955 of which were returned. Questions elicited categorical answers, either dichotomous or multiple choice. Data were evaluated using logistic regression and the chi-square and binomial tests. Our results show that 60 percent (p < 0.01) of plastic surgeons routinely perform a less than optimal procedure on their patients who smoke. The survey measured willingness to perform various operative procedures on patients who smoke and types of smoking cessation aids offered. Of those physicians who require patients to quit smoking before surgery, only 16.7 percent (p < 0.01) would perform a nicotine test if they suspected noncompliance. Interestingly, 28.6 percent (p < 0.01) of the physicians responding admit to a smoking history, whereas only 1.5 percent (p < 0.01) continue to smoke, compared with the national smoking rate of almost 25 percent. Physicians who are previous smokers are less likely to offer smoking cessation aids than those who have never smoked, and the proportion not offering aids increases as the amount of previous smoking increases (p = 0.02). This study shows that a wide range of opinions exists on which elective surgical procedures should be performed on patients who smoke. Furthermore, the physician's prior smoking history influences this decision. No clear consensus exists on how best to treat patients who smoke who request elective surgeries. Although surgeons would prefer to operate on nonsmokers, they are faced with a significant population of patients who use tobacco. No clear consensus exists on how best to treat these individuals. Advancements in wound healing research and smoking cessation aids will provide more insight into this treatment dilemma.     

Five-year history of the American Society of Plastic and Reconstructive Surgeons, 1974--1978.

This report was intended to summarize the significant happenings in the American Society of Plastic and Reconstructive Surgeons, and its affiliates, from the end of the annual meeting in 1973 to the end of the 1978 annual meeting. It was decided to not include our sister organizations--the American Association of Plastic Surgeons, the American Society for Aesthetic Plastic Surgery, the American Society of Maxillofacial Surgeons--because their historians publish periodic reports about their activities. I am sure that the future reports of historians will record with pride the continued growth and development of plastic surgery, because the future of our specialty has never seemed brighter.     

Practice advisory on liposuction

COMMITTEE STATEMENT: At the 69th annual meeting of the American Society of Plastic Surgeons (ASPS) in October of 2000, the ASPS Board of Directors convened the Task Force on Patient Safety in Office-Based Surgery Facilities. The task force was assembled in the wake of several highly publicized patient deaths involving plastic surgery and increasing state legislative and regulatory activity of office-based surgery facilities. In response to the increased scrutiny of the office-based surgery setting, the task force produced two practice advisories: "Procedures in the Office-Based Surgery Setting" and "Patient Selection in the Office-Based Surgery Setting." Since the task force's inception, professional and public awareness of patient safety issues has continued to grow. This heightened interest resulted in an increased need for plastic surgeons to communicate their views on the topic. To meet this challenge, the task force evolved into the Committee on Patient Safety, allowing the committee to address topics affecting the safety and welfare of plastic surgery patients, regardless of the facility setting. The "Practice Advisory on Liposuction" is the first advisory developed since the committee was formed. It was a lengthy and painstaking process for the committee, which included representatives from related plastic surgery organizations as well as the American Society of Anesthesiologists (ASA). Committee members included Ronald E. Iverson, M.D., chair; Jeffery L. Apfelbaum, M.D., ASA representative; Bruce L. Cunningham, M.D., ASPS/Plastic Surgery Educational Foundation (PSEF) Joint Outcomes Task Force representative; Richard A. D'Amico, M.D., ASPS representative; Victor L. Lewis, Jr., M.D., ASPS Health Policy Analysis Committee representative; Dennis J. Lynch, M.D., ASPS representative; Noel B. McDevitt, M.D., ASPS Deep Vein Thrombosis Task Force representative; Michael F. McGuire, M.D., The American Society for Aesthetic Plastic Surgery (ASAPS) representative; Louis Morales, Jr., M.D., American Society of Maxillofacial Surgeons representative; Calvin R. Peters, M.D., Florida Ad Hoc Commission on Patient Safety representative; Robert Singer, M.D., American Association for Accreditation of Ambulatory Surgery Facilities representative; Thomas Ray Stevenson, M.D., American College of Surgeons representative; Rebecca S. Twersky, M.D., ASA representative; Ronald H. Wender, M.D., ASA representative; and James A. Yates, ASAPS representative. The authors thank members of the committee for the insights they brought to this process. The final document represents their significant contributions to these efforts. They would also like to recognize DeLaine Schmitz and Pat Farrell of the ASPS staff for their work on and support of this project.     

Safety and efficacy of office-based surgery with monitored anesthesia care/sedation in 4778 consecutive plastic surgery procedures

Office-based surgery has several potential benefits over hospital-based surgery, including cost containment, ease of scheduling, and convenience to both patients and surgeons. Scrutiny of office-based surgery by regulators and state-licensing agencies has increased and must be addressed by improved documentation of safety and efficacy. To evaluate the safety and efficacy of the authors' office-based plastic surgery, a review was undertaken of 3615 consecutive patients undergoing 4778 outpatient plastic surgery procedures under monitored anesthesia care/sedation in a single office. The charts of 3615 consecutive patients who had undergone office-based surgery with monitored anesthesia care/sedation between May of 1995 and May of 2000 were reviewed. In all cases, the anesthesia protocol used included sedation with midazolam, propofol, and a narcotic administered by a board-certified registered nurse anesthetist with local anesthesia provided by the surgeon. Charts were reviewed for patient profile, types of procedures, multiple procedures, duration of anesthesia, American Society of Anesthesiologists class, and complications related to anesthesia. Outcomes measured included death, airway compromise, dyspnea, hypotension, venous thrombosis, pulmonary emboli, protracted nausea and vomiting lasting more than 24 hours, and unplanned hospital admissions. Statistical analyses were performed using the Microsoft Excel program and the SAS package. Results were as follows: 92.3 percent of the patients were female and 7.7 percent were male, with a mean age of 42.7 years (range, 3 to 83 years). Patients underwent aesthetic (95.6 percent) and reconstructive (4.4 percent) plastic surgery procedures. Same-session multiple procedures occurred in 24.8 percent of patients. The vast majority of patients were healthy: 84.3 percent of patients were American Society of Anesthesiologists class I, 15.6 percent were class II, and 0.1 percent were class III. The operations required a mean of 111 minutes. There were no deaths, ventilator requirements, deep venous thromboses, or pulmonary emboli. Complications were as follows: 0.05 percent (n = 2) of patients had dyspnea that resolved, 0.2 percent (n = 6) of patients had protracted nausea and vomiting, and 0.05 percent (n = 2) of patients had unplanned hospital admissions (<24 hours). One patient had an emergent intubation. No prolonged adverse effects were noted. There was a 30-day follow-up minimum. Outpatient surgery is an important aspect of plastic surgery. It was shown that office-based surgery with intravenous sedation, performed by board-certified plastic surgeons and nurse anesthetists, is safe. Appropriate accreditation, safe anesthesia protocols, and proper patient selection constitute the basis for safe and efficacious office-based outpatient plastic surgery.     

Wendell L. Hughes' life and contributions to plastic surgery

Wendell L. Hughes was a pioneer in ophthalmic plastic surgery and best known for the "Hughes flap," a tarsoconjunctival flap used for lower eyelid reconstruction. In 1937, Wendell L. Hughes sought to achieve the criterion standard of replacing "like with like" in his development of the tarsoconjunctival flap for lower lid reconstruction. This work was published in his ground-breaking thesis, Reconstructive Surgery of the Eyelids, the most comprehensive book on ophthalmic plastic surgery of its time. Although this flap has undergone many modifications, it has stood the test of time and is still used today. In addition, Dr. Hughes was heavily involved in surgical education, a founding member of the American Board of Plastic Surgery, and a leader in the development of sutures and microneedles. More importantly, he was a gracious humanitarian and inspiring mentor loved by peers and patients alike. Other authors have reviewed the intricacies of the Hughes flap; however, little attention has been given to the contributions of its creator.     

Rhinophyma: dispelling the myths

Rhinophyma is a relatively common condition in the west of Scotland. The Canniesburn Plastic Surgery Unit receives 12 to 13 new patients per year for surgical treatment. The reported incidence of simultaneous carcinoma in the setting of rhinophyma is on the order of 15 to 30 percent. There are conflicting reports about the association between alcohol and rhinophyma in the literature, and these are supported with little or no statistical evidence. Retrospective epidemiologic data on 45 cases of rhinophyma are presented. An audit of case notes was performed to examine histology and also alcohol consumption in these cases. The authors found no coincidental malignancies at the time of surgery, which is contrary to many previous publications. The alcohol consumption of the rhinophyma cases was compared with that of a control group that consisted of 48 men presenting for blepharoplasty. The series did not demonstrate a positive association between alcohol and rhinophyma when compared with a similar cohort of patients presenting for blepharoplasty surgery (p > 0.20) or with statistics available from the Scottish Health Survey.     

Surgical treatment of migraine headaches by corrugator muscle resection

The authors, a plastic surgeon (Dirnberger) and a neurologist (Becker), conducted this study after reading the article by of Bahman Guyuron et al. in the August 2000 issue of Plastic and Reconstructive Surgery (106: 429, 2000). Sixty patients were operated on between June of 2001 and June of 2002; postoperative follow-up ranged between 6 and 18 months. Patients' charts were reviewed to confirm the diagnosis of migraine headache according to the criteria of the International Headache Society. Sixty patients (13 men and 47 women) from Austria and four neighboring countries took part in the study. The patients were divided into three groups, based on the severity of their migraines: group A comprised patients with up to 4 days of migraine per month; group B included patients with 5 to 14 days of migraine per month; and group C was composed of patients with more than 15 days of headache per month ("permanent headache") or evidence of drug abuse and drug-related headaches. The effectiveness of the operation was evaluated using the following factors: percentage reduction of headache days; percentage reduction of drugs; percentage reduction of side effects, severity of headaches, and response to drugs; and patient grade of personal satisfaction, using a scale from 1 to 5 [1 = excellent (total elimination of migraine headache) to 5 = insufficient or no improvement]. From the entire group of 60 patients, 17 (28.3 percent) reported a total relief from migraine, 24 (40 percent) reported an essential improvement, and 19 (31.7 percent) reported minimal or no change. Patients with a rather mild form of migraine headache had a much better chance (almost 90 percent in group A and 75 percent in group B) to experience an improvement or total elimination of migraine than those patients (n = 27) from group C with severe migraine, "permanent headaches," and drug-induced headaches. Contrary to the reports by Guyuron, 11 patients who had a very favorable response immediately and in the first weeks after the operation experienced a gradual return of their headaches to preoperative intensity after about 4 postoperative weeks. After 3 months, the results in all patients could be declared permanent. All side effects, such as paraesthesia in the frontal region, disappeared in all patients within 3 to 9 months.     

Current preferences for breast reduction techniques: a survey of board-certified plastic surgeons 2002

The purpose of this survey was to assess the current trends in breast reduction techniques and to compare satisfaction rates and complications associated with traditional incision and limited incision techniques. In September of 2002, a breast reduction survey was sent to 1500 members of the American Society for Aesthetic Plastic Surgery; 554 of the members returned the survey. Questions elicited categorical answers, and the data were evaluated using the chi-square test and the comparison of two proportions. The results showed that 56 percent of the respondents use only the inferior pedicle and Wise pattern techniques, whereas 6.9 percent of the respondents use only the limited incision techniques. Physician satisfaction was rated as 4 on a scale of 1 (unsatisfied) to 5 (very satisfied) for both the limited incision and traditional incision groups. Patient satisfaction was rated as 4 for the limited incision group and as 5 for the traditional incision group. This difference in patient satisfaction per surgeon was statistically significant (p < 0.05). The traditional group reported a lower complication rate than did the limited incision group (p < 0.05). The most frequent complications for the traditional incision group were compared with those of the limited incision group. Practice profiles, liposuction, and opinions regarding future changes in breast surgery were also analyzed. The majority of surgeons reported that they did not anticipate changing their practices to accommodate advances in limited incision techniques; however, 89 percent reported that the new limited incision techniques and liposuction are trends that are here to stay.     

Authorship and medical ghostwriting: Plastic and Reconstructive Surgery policy

Authorship of biomedical articles serves to acknowledge and credit individuals who contributed substantially to the development, writing, and editing of articles. In addition, authorship indicates who is responsible for ideas and experiments, and can be used to hold people accountable if something is disproven or shown false. Types of authorship can be divided into four primary categories: ghost authorship, guest authorship, gift authorship, and legitimate authorship. Of these four categories, Plastic and Reconstructive Surgery (along with other journals, the World Association of Medical Editors, the International Committee of Medical Journal Editors, the Council of Science Editors, and the Committee on Publication Ethics) affirms that only authors who meet the criteria of "legitimate authorship" as authors should be listed on an article. This article discusses what constitutes legitimate article authorship and sets forth the Journal's policy on authorship.