What should you know about the safety of outpatient plastic surgery?

When considering plastic surgery, it’s natural to focus more on the expected result than on the surgical process. However, to be fully informed, it’s important to learn about the safety of the procedure as well as the expected outcome. Although thousands of people have plastic surgery every year without complications, no surgical procedure is risk-free. To maximize safety, ensure that:

• Your surgeon is adequately trained and is board certified by the American Board of Plastic Surgery;
• The facility where your surgery will be performed conforms to strict safety standards;
• Your surgeon is informed of any drugs you are taking and your full medical history, especially if you have had any circulation disorders, heart or lung ailments or problems with blood clots;
• The surgical facility will use skilled, licensed personnel to administer and monitor your anesthesia and your recovery immediately following the procedure
• Extra safety measures are taken if you are having a more extensive liposuction procedure.

The American Society of Plastic Surgeons (ASPS), an organization of board-certified plastic surgeons who are dedicated to the highest standards of patient care, has prepared this document to help you get the safety information you need. It contains recommendations developed by the society’s expert task forces, whose members have consulted the most recent research available. If you have questions about these guidelines or any specific concerns not covered in this document, talk with your board-certified plastic surgeon. Only ASPS members are entitled to display the logo above.

How can I be sure that my surgeon has adequate training?

Good credentials can’t guarantee a successful outcome; however, they can significantly increase the likelihood of it. Patients are advised to find a doctor who is certified by the American Board of Plastic Surgery (ABPS), the only board recognized by the American Board of Medical Specialties to certify a surgeon in plastic surgery of the face and of the entire body. Certification by the ABPS is “the gold standard” for plastic surgeons because it signifies that the surgeon has had formal training in an accredited plastic surgery residency program. If your surgeon is ABPS-certified, you can be assured that your doctor:

• Has completed at least five years of surgical residency training after medical school, including at least two years in plastic surgery
• Has passed comprehensive cosmetic and reconstructive surgery exams
• Is qualified to perform cosmetic and reconstructive procedures – everything from liposuction and facelifts to intricate wound repair.

To verify a surgeon’s certification status, contact the American Board of Plastic Surgery at 215-587-9322 or visit the board’s web site at www.abplsurg.org or the American Board of Medical Specialties at www.abms.org or by phoning 1-800-776-2378

How can I determine if my plastic surgeon’s surgical facility meets acceptable safety standards?

The American Society of Plastic Surgeons and the American Society for Aesthetic Plastic Surgery have issued a statement to their members that by July 1, 2002 all plastic surgery performed under anesthesia, other than minor local anesthesia and/or minimal oral tranquilization, must be performed in a surgical facility that meets at least one of the following criteria:

• Accredited by a national or state recognized accrediting agency/organization such as the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), Accreditation Association for Ambulatory Health Care (AAAHC), or Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
• Certified to participate in the Medicare program under Title XVIII
• Licensed by the state in which the facility is located

Patients should ensure that the facility is accredited or is in the process of being accredited. To find out about a facility’s accreditation status, contact the AAAASF at 1-888-545-5222 or www.aaaasf.org the AAAHC at 847-853-6060 or www.aaahc.org the JCAHO at 630-792-5005 or www.jcaho.org.

Plastic surgery procedures performed in accredited surgical facilities by board-certified plastic surgeons have an excellent safety record. A 1997 survey 1 based on more than 400,000 operations performed in accredited facilities found that:

• The rate of serious complications was less than half of 1 percent.
• The mortality rate was extremely low – only one in 57,000 cases.
• ” The overall risk of serious complications in an accredited office surgical facility is comparable with the risk in a freestanding surgical center or hospital ambulatory surgical facility.

Why is it so important for my plastic surgeon to know detailed information about my personal and family health history, even if I am only having a simple cosmetic procedure?

There is always risk with any surgical procedure. However, as a patient, you can play an important role in reducing your risk by providing a full and complete health history to your surgeon.

Although rare, one of the most serious complications associated with surgery is the development of blood clots in the large veins of the abdomen and legs. This complication can lead to a potentially fatal pulmonary embolism (blocked lung artery). Therefore, it is extremely important to tell your plastic surgeon if you or any of your family members have a history of blood clots or if you have had a family member who died suddenly, shortly after surgery or childbirth.

You will also be evaluated for other factors that may increase the risk of blood clots. These include:

• Being extremely overweight
• Having recent traumatic injury
• Any disorder of the heart, lungs or central nervous system
• A history of cancer, recurrent severe infection or genetic problems that affect blood clotting

For women, additional risk factors include:

• Taking oral contraceptives or having recently ceased taking them
• Undergoing hormone-replacement therapy

Safety measures to prevent blood clots will be determined by your individual degree of risk. If you are considered low risk, your doctor may simply ensure that you are positioned on the operating table in a way that allows for adequate blood circulation to the legs. If you are of moderate or high risk for developing blood clots, you may also be advised to wear elastic stockings before, during and after your procedure, or to take special anti-clotting medications. Compression devices on the legs may be used during surgery to support your normal circulation.

How can I be sure that the anesthesia care I receive in my plastic surgeon’s surgical facility is adequate?

Anesthesia care in an accredited or licensed facility has reached a level of sophistication that is absolutely comparable to the care received in the hospital. For maximum safety, ASPS recommends that:

• Any planned anesthesia should be administered by skilled, licensed personnel acting under the direction of an anesthesiologist or the operating surgeon.
• Before any type of anesthesia is used, the surgeon or anesthetist must take a full medical history. A physical examination and appropriate lab tests may also be performed. Your surgeon needs to know if you have any serious medical problems or have had previous adverse reaction to any other type of anesthesia. Also, you must let the anesthetist know about any medications you are taking (including herbal supplements), any known drug allergies, when you last ate and whether you smoke cigarettes or use alcohol or illegal drugs.
• You should be assured that you will receive individual monitoring by skilled, licensed personnel before, during and after the procedure. Staff who are familiar with the warning signs of cardiac or respiratory distress and are trained in advanced cardiac life support (ACLS), should be on hand to monitor your procedure and recovery following your surgery.
• If you are told that you will be kept overnight at the surgical facility while you recuperate, make sure that the facility is accredited by a recognized agency. In an accredited facility you will receive around-the-clock care and monitoring by two or more skilled and licensed staff members with at least one trained in ACLS. You will also be assured that the facility has the necessary equipment and medications to handle complications that may arise and an emergency plan in case you need to be transferred to the hospital.

To achieve the cosmetic results I want, my plastic surgeon has recommended “large-volume” liposuction. What types of safety measures should I expect my surgeon to take?

Due to recent advances in technique and technology, serious medical complications in liposuction are quite rare. However, the risk of complications increases with the number of areas treated and the amount of fat removed. A liposuction procedure is classified as “large volume” when 11 pounds (5,000 cc) or more of fat and fluid are removed.

Factors that may increase the risk of complication are:

• Excessive amounts of local anesthesia or excessive amounts of fluid administered intravenously or within the tissues at the surgical site
• Multiple, unrelated procedures performed during the same surgery
• Being in poor health prior to surgery
• Having a personal or family history of blood clots of the legs or a blocked lung artery
• Having a personal or family history of breathing or bronchial disorders or other lung problems
• For women: Current use of oral contraceptives

For maximum safety, a patient planning to have either large-volume liposuction or ultrasound-assisted liposuction (known as UAL) should be aware of the following:

• Large-volume liposuction requires specialized knowledge. Therefore, it’s important for your surgeon to have additional training specifically in UAL or large-volume liposuction.
• Your surgeon should keep track of the amount of fluid that is infused into your body and the amount that is withdrawn from your body. The surgeon should also have systems to record intravenous fluid, the amount of fat removed and urinary output.
• Extended post-operative monitoring of vital signs and urinary output is critical following large-volume liposuction. An overnight stay in a hospital or other overnight-stay-accredited facility may be required.

ASPS believes that in the hands of an appropriately trained specialist, liposuction is a generally safe procedure. Still, ASPS is collecting additional data on the safety and effectiveness of liposuction. The Liposuction Outcomes Study and will yield valuable data in the near future.

Safety is a team effort

Quality patient care, safety and successful surgical outcomes are the result of the patient, the surgeon and the surgical staff working together. The ASPS has supported this concept by establishing task forces on liposuction, deep vein thrombosis prophylaxis and outpatient surgical safety. These professional groups have thoroughly investigated the surgical techniques, equipment and medications commonly used in outpatient plastic surgery and have set safety guidelines for use by all plastic surgeons, their staffs and their facilities. The task forces have also supplied the patient-safety information for this document.

As the ASPS continues to support the safety research being conducted by its Educational Foundation and the National Endowment for Plastic Surgery, patients are encouraged to learn everything they can about the procedures they are considering and to ask a lot of questions. Your concerns about safety should be discussed in detail with your plastic surgeon. This will help promote a safe outpatient surgery experience as well as fulfilling your surgical expectations.

1. Morello, D.C., Colon, G.A., Fredericks, S., Iverson, R., Singer, R. Patient safety in accredited office surgical facilities. Plast. Reconstr. Surg. 99: 1496, 1997.

Statement approved by the ASPS Board of Directors, June 24, 2000