- HEALTH TRACKER
|by Don Revis, MD, FACS, PA
After losing a considerable amount of weight, many bariatric patients will turn to a plastic surgeon to contour their bodies and remove the excess, sagging skin. The more information you have beforehand, the more you will be able to absorb during the consultation without being overwhelmed. With a list of questions prepared prior to your visit, you can make sure you don’t forget to ask anything essential.
Choosing a plastic surgeon is a very important decision that should be made very carefully. Consider at least three board-certified plastic surgeons before making your decision. Some surgeons may have more experience than others with the surgical procedures you are interested in, while other surgeons may have more recent or more extensive training in the latest surgical techniques. Ask your bariatric surgeon and other bariatric patients for their recommendations, and make sure the surgeon you are considering is board certified by the American Board of Plastic Surgery and is a member of the American Society of Plastic Surgeons (www.plasticsurgery.org), the largest plastic surgery organization.
It may also be helpful to have someone accompany you to your consultation, because the opinion of a trusted friend, relative or significant other may be extremely valuable.
The Surgeon’s Office
Upon arrival to the physician’s office, typically you will be greeted by a receptionist and asked to fill out a new patient information form. When completing this form, be completely honest and thorough, as the information you provide helps to prevent complications during your care. When asked about medications, be sure to include any vitamin or herbal preparations, as these can affect your blood pressure and clotting ability. Honesty regarding your use of tobacco and alcohol also is very important, as this may have a profound impact on your recovery period and incision healing.
Before Meeting the Surgeon
Initially, you may meet with a nurse or a patient coordinator. This staff member is familiar with the surgeon’s style and aesthetic sense and usually can competently assess a patient and answer many questions. This staff member also may become your liaison with the physician when the physician is not immediately available. You will come to know the nurse or patient coordinator quite well over the
course of your surgery and recovery period, so it is wise to befriend this important staff member.
You may be provided with a tour of the facility, particularly if the physician performs surgery in the office. Take note of the cleanliness of the facility. Would you feel comfortable having surgery performed in the office?
A chaperone (the nurse or patient coordinator) should be present when the surgeon is in the room with you. The chaperone acts as a witness to corroborate or deny any claims of untoward behavior between physician and patient. The door should be left ajar if the chaperone has to leave the room.
Meeting the Surgeon
Finally, you will meet the surgeon. The length of the initial consultation may be as brief as 15 minutes or longer than an hour, depending on the complexity of the issues involved. Initial impressions are extremely important; they may indicate immediately whether or not the surgeon is someone you wish to trust.
The surgeon will introduce himself or herself and offer a few introductory remarks. Feel free to ask about the surgeon’s background. A well trained surgeon is proud of his or her accomplishments and will gladly share them with you. You also have a right to know the status of malpractice claims and awards. It should not be considered an insult to inquire about these issues. Avoid a surgeon who has multiple malpractice claims or awards. Also make sure that the surgeon carries malpractice insurance; not all states require physicians to do so.
Several factors regarding surgery should be discussed with the physician during initial consultation, including procedure, location, anesthesia, recovery and cost. The surgeon should inquire about your concerns, priorities and motivations for pursuing surgery, as well as your fears.
The surgeon also should try to ensure that you have reasonable expectations for the outcome, and should explain what is possible and what is not possible.
Questions You Should Ask About the Procedure
• What is the simplest and safest surgery to help me achieve my goals?
• How is the surgery performed?
• What is the expected length of operation?
• Are other options available?
• What results can I expect, and how long do the typical results last?
• Where will scars be located, and how noticeable will they be?
• Will scars fade over time, and how long will this take?
Avoid the surgeon who does things only one way. The beauty of cosmetic surgery is that there are many ways of accomplishing the desired result. Your surgeon should be able to discuss options with you, fully explaining the advantages and disadvantages of each and why one may be recommended over another.
Questions You Should Ask About the Surgeon’s Experience With the Procedure
• How many times has the surgeon performed this procedure?
• How long has the surgeon been performing this procedure?
• How many times per year does the surgeon perform the procedure?
• How many patients have required re-operation or touch ups?
• What complications may occur?
• How frequently do these complications occur?
Avoid the surgeon who is not appropriately trained in the type of surgery you desire. Another key aspect is to review photos of actual bariatric patients who have had the same procedure you desire. If the surgeon cannot show you any pre and post-operative photos, it is likely that he or she is inexperienced in the procedure. Conversely, if the surgeon can show you numerous examples of his or her work with bariatric patients, you can rest assured that this surgeon probably has a thorough knowledge of and experience with bariatric patients
and their special needs surrounding surgery.
Questions You Should Ask About Logistical Matters
• What preparation is required the day before and morning of surgery?
• Should my regular medications be taken on the morning of surgery?
• What time should I arrive at the surgery location?
• Should someone drive me?
• Should someone wait at the surgery location or come back later?
The surgeon also will discuss smoking with you. Smoking may lead to severe complications and wound healing problems. Your surgeon may not perform certain procedures if you are unwilling to quit smoking for a certain period of time pre- and post-operatively. Cosmetic surgery offers a chance to change your life. You can improve your appearance through surgery and improve your health through smoking cessation and improved diet and exercise habits. You should end up looking better, feeling better, and living longer.
Where Your Surgery Will Be Performed
Sometimes you have a choice in the location of your surgery, whether in a hospital, ambulatory surgery center, or office surgery setting. Some surgeons prefer to perform the majority of their procedures in their own office surgery suites as a convenience to themselves and to save money. Others prefer to do only minor procedures in the office while performing more major operations in a local hospital or ambulatory surgery center. The factors to be considered when choosing between office and hospital surgery are discussed below.
Office Surgery Suites
Many physicians have surgical suites in their offices where they perform the majority of their operations. Escalating costs of hospital care and the ability of properly trained physicians to perform procedures safely in properly accredited office surgery settings influenced the growth in office-based surgery. Due to the differences in overhead, procedures performed in an office setting often are slightly less expensive than those performed in a hospital or ambulatory surgery center.
Any physician, regardless of his or her training, can open an office surgery suite and advertise as a plastic surgeon and perform plastic surgery on the unsuspecting public. Regulation of office surgery settings is currently voluntary and often substandard. New laws are being passed in an attempt to correct this potential problem. If you decide to have your surgery in an office surgery suite, choosing a physician whose surgery suite is accredited adds an additional level of quality assurance. The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), www.aaaasf.org, is one organization that provides accreditation for office operating rooms.
Despite thorough training of physicians and staff and accreditation of facilities, emergencies can occur during an office procedure. Emergency plans must be in place and be able to be activated immediately. The surgeon and staff must be familiar with how to activate the emergency system and what each person’s role is in the event of an emergency situation.
• What emergency plans and equipment are in place to provide for my needs in the event of an emergency?
• Are the surgeon and staff certified in Advanced Cardiac Life Support (ACLS)?
• Does the surgeon have admitting privileges at a local hospital should problems arise during my office surgery? (Call the hospital to confirm.)
• How would I be transported to this facility?
• Has an adverse event ever occurred in the past?
Do not have surgery performed in any office where you are uncomfortable with the emergency procedures.
Hospital or Ambulatory Surgery Center
Broad Range of Services
Hospitals provide a broad range of services and have specialists available should any serious complications arise. If you have other medical conditions that make the proposed procedure more risky than usual, your surgeon may opt to perform the procedure in a hospital setting.
To obtain hospital privileges to perform a procedure, surgeons must provide proof of education, training, and experience. This provides an added level of assurance that the surgeon has been properly educated and trained.
Much like board certification for a physician, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), www.jcaho.org, establishes a baseline standard of excellence among hospitals and is recognized nationwide. You should ask if the hospital where your surgery will be performed is accredited by JCAHO.
Avoid a surgeon who operates in his or her office but does not have hospital privileges to perform the same operation. Also avoid a surgeon who operates in his or her office without some accreditation by an ambulatory surgery accreditation association. And finally, avoid any physician claiming to be a plastic surgeon or cosmetic surgeon who is not certified by the American Board of Plastic Surgery.
Anesthesia is a complex and essential part of any surgical procedure and must be performed safely. Anesthesiologists and certified nurse anesthetists are specialists with experience in administration of all types of anesthesia.
The deepest form of anesthesia is called general anesthesia. The person providing anesthesia takes over the responsibility of breathing for you. You are sedated and feel no pain. You are unconscious during the procedure and will not remember it.
Deep Intravenous Sedation
Deep intravenous sedation, termed by some as “twilight sleep,” is a combination of local anesthetic injected at the site of surgery and intravenous sedation. You breathe for yourself, but you are in a deep sleep throughout the procedure and feel no pain. More than likely,
you will not remember the procedure.
Local anesthetics alone may be used for certain small procedures. The operative site is numbed, but you remain wide awake and aware of the procedure being performed. To prevent anxiety, you may be given a small amount of sedation orally, intravenously, or intramuscularly.
Meeting the Anesthesia Provider
You should ask to meet your anesthesia provider prior to surgery. This gives you the opportunity to discuss with your provider the appropriate type of anesthesia for your proposed surgery and any specific concerns regarding your safety and health.
Recovering From Your Procedure
The recovery period is an important part of the recovery process.
• What kind of care will I require?
• When will I be able to go home? Is an overnight stay required, or is one available if I prefer?
• Who will attend me in the case of an overnight stay?
• Will I need someone to drive me home?
• If a problem arises after I go home, who answers calls after hours and on weekends?
• If I need to be seen after hours, where will this occur?
• If I need help in my home, is a private duty nurse available? At what cost?
• Are any special garments, medications, or diets required during the recovery period?
• How much pain/swelling/bruising is to be expected? How long are these likely to last?
• How long does the entire healing process last?
• How many follow-up visits are necessary?
• Who performs the skin care/post-operative follow-up/suture removal? (In some offices, these functions are delegated to the staff.)
• When can I wear makeup?
• When may I return to exercise/bathing/driving/normal activities/work?
• At what point will I feel comfortable in a social setting?
• What if I am dissatisfied with the results or with the degree of changes achieved?
• If touch ups are necessary, when would these be performed?
Answers to these questions will help you properly prepare for the postoperative period.
Cost of Your Procedure
During the information-gathering phase of your search, you may have obtained fee information by phone. During the consultation, you will receive a quote of the surgery fees, which should be provided in written form for you to take with you.
In competitive regions, surgeons tend to waive consultation fees. In areas with fewer surgeons, consultation fees may not be waived. Even within highly competitive markets, however, some surgeons may charge fees while others may not.
Surgical fees vary state to state and within the same city or region. Legally, surgeons cannot discuss fees with other surgeons, so fees may fall over a very wide range. You should not judge a surgeon’s skills by the fees charged. You can, however, determine if you can afford a physician.Do not waste your time or the physician’s by visiting for a consultation if you cannot afford the fees.
Make sure that the fees you are quoted are global fees (i.e., all costs are included). The costs typically involved in surgery include the surgeon’s fee, the fee for anesthesiology, and facility fees; implants or other prostheses, special garments, perioperative skin care required, and preoperative testing and examination costs.
Questions to Ask About Fees
• Does the cost depend on where my surgery is performed?
• Will I need to see another physician prior to surgery for examination or testing because of a preexisting medical condition? Who pays this cost? Will my regular family doctor suffice?
• If a complication causes me to be transported to a hospital or stay overnight, who pays for this additional cost?
• If I request multiple procedures, can they be performed at the same time? What are the cost savings?
Do not feel pressured to have more surgery than you want or perceive you need, even if the surgeon offers you a significant “discount” for multiple procedures. Avoid the surgeon who tries to sell unwanted additional procedures.
Touch ups may be required, particularly with liposuction, and do not indicate error or negligence on the part of the surgeon. Touch ups are an inherent risk of some procedures and should be explained preoperatively. Be sure to ask who will absorb the cost of any necessary revisions or touch ups. Frequently, the surgeon charges only the facility and anesthesiology fee for revisions and touch ups and waives the surgeon’s fee.
If the surgeon operates in his or her office, you probably will be asked to pay one lump sum prior to surgery. If the surgeon operates in a hospital or ambulatory surgery center, it may work one of two ways: the surgeon may collect the entire fee and reimburse the hospital, or you may be asked to make part of the payment to the surgeon and the remainder to the hospital.
Questions to Ask About Payment Policies
• What options are available for payment?
• Does the office accept credit cards?
• Is a payment plan available to patients?
• What is the refund policy should I change my mind after paying in full?
• Is my surgery covered by my insurance plan?
Certain procedures, such as upper eyelid surgery in the case of severely compromised vision, may be covered by your insurance plan.
Some physicians use photographic imaging to project what you might look like after surgery, but these are computer simulations. Be aware that these images are a marketing tool only and represent an ideal goal; in no way do these images guarantee your outcome or the skill of the surgeon.
The surgeon also may display photos of prior patients who underwent your proposed procedure. Again, these photos are not a guarantee of the results you will achieve. The photos will give you an idea of the best results in this surgeon’s hands and give you an appreciation of the surgeon’s aesthetic sense. If the surgeon shows you only beautiful results, ask to see photos of bad results, particularly poor scarring and wound healing and patients needing touch ups. Do not believe a surgeon who claims to have encountered no complications or have no photographs of bad results.
Being photographed may be unsettling, particularly if breasts or genitalia are exposed. However, this is an essential part of the planning
process. These photos will be used to plan the operation and provide a record of your preoperative appearance.
Making Your Decision
After discussing all of the factors involved with your proposed procedure with the surgeon, you should have a sense of whether or not the surgeon is right for you. Take note of and consider whether the surgeon:
• Listen and understand your priorities, opinions, and requests?
• Communicate concern, compassion, respect and honesty?
• Instill confidence in you?
• Display confidence in his or her ability to care for you?
• Seem distracted, or come across as arrogant or curt?
• Seem patient and willing to spend the time to answer all your questions and discuss your concerns?
• Condescend, talk down or under estimate your intelligence?
• Make eye contact or continually jot down notes in the chart as you spoke?
• Display positive body language?
• Confuse you or offer you clear explanations?
• Appear to be selling you the procedure?
• Adequately discuss any preexisting medical conditions you might have?
• Encourage your family to participate in the consultation and decision-making process?
• Feel that you have established forthright communication and a positive rapport with the surgeon?
• Trust your life to this surgeon?
• Feel the surgeon is acting in your best interest?
Answers to these questions should provide you with the comfort you need to choose this surgeon. However, because you will have been overwhelmed with information in an unfamiliar environment, you are urged not to make any hasty decisions.
It may take several visits to the same surgeon’s office before you have all of your questions answered and are ready to commit. Do not feel pressured to sign up for surgery on the spot. Any reasonable surgeon understands you may need time to think it over and discuss it with family, personal physician or other surgeon.
You may want to plan your surgery to take advantage of vacation time from work. A certain time of year also might be better if you are less busy. Summer can be a good time to have elective surgery, because many people confine their activities to the indoors due to the heat and UV rays.
The decision for surgery is an important one. Explore and evaluate the opinions of family and trusted friends. However, the final decision should be yours. The surgeon should not be allowed to make your decision for you, nor should you expect that from the surgeon. Each person has a unique self-image and sense of beauty, and it is important for your surgeon to understand your feelings and to work with you to help you achieve your goals.
Good luck in finding Dr. Right. However, realize that in addition to luck, or perhaps in place of it, it takes time and dedication to do the appropriate background checks to be an informed consumer in the world of elective cosmetic surgery. You will know when you have found the right combination of surgeon, procedure, timing and cost.
Don Revis, Jr., MD, FACS is a double board certified plastic surgeon in private practice in Ft. Lauderdale, Florida. He dedicates 50% of his practice to the body contouring needs of bariatric patients. Please visit www.SouthFloridaPlasticSurgery.