Abdominoplasty Letter to Cosmetic Surgery Times
COSMETIC SURGERY TIMES
July 11, 2001
To: the Editor
I enjoy Cosmetic Surgery Times, and particularly appreciate your request for your authors to document the number of cases they have performed of a given procedure. This helps distinguish the experience level of the authors, and I occasionally find some well-published individuals with less than 100 cases(!) There is a place for reporting of the latest trends, even when they are not peer reviewed.
My comments follow regarding your recent abdominoplasty article regarding the work of Dr Neil Bisaccia and Dwight Scarborough in the Jan/Feb issue and the commentary by Dr Aaron Stone in April 2001.
There are three issues here:
- What is the place of abdominoplasty?
- What is the identity and character of the different specialties?
- Are there rules of engagement here for writing about our peers?
The first two issues have to do with us, the doctors, and the last with you, the publication.
I regard abdominoplasty as a faulty surgery which is far, far oversold by some of my aggressive colleagues. In my opinion: 95 per cent of abdominoplasties are unnecessary, dangerous, and cosmetically destructive. Clear and well-accepted study shows that this procedure has a fatality rate of between one in 600 (comparable to hang gliding) and one in two thousand. (1,2) It's not hard to imagine the serious complication rate transfusion, skin slough, hospitalization, pulmonary embolism that accompanies this death rate. I would challenge any physician to get together in one room their last 25 abdominoplasty patients for an honest evaluation of their cosmetic results. The literature is vague, indeed, as to the patient satisfaction from this procedure
The basic premise of abdominal wall tightening is flawed (see accompanying photographs). Many of these patients are obese. If the abdomen wall is plicated, frequently with weight gain and intra-abdominal fat deposition, the abdomen becomes tight as a drum and I have seen hernias develop as a result. And I see many young women of child bearing age "tummy tucked". The only appropriate patient for this procedure is a rare thing indeed: a thin patient with a stretched abdominal wall (but most overweight patients will have a flat abdomen if they lose weight, even if the muscle and fasca is very stretched). The other premise, that the skin is like a paper bag, and needs to be cut and pasted in place, makes no sense to experienced liposuction surgeons. We know that the skin is more like a rubber band, with great elasticity and potential for contraction.
Regarding the character of the different specialties: we are all individuals, and modern training is mostly outside of residency. In fact, famous plastic surgeons have denigrated the quality of their own residency training (3,4,5). Is stereotyping dermatologists as not fit for "serious surgery" an appropriate comment for publication in a national trans-specialty magazine? I leave it to the reader and the kind editors to decide.
Dermatologists have arguably added more to the cosmetic surgery literature than any other group in the last 15 years. Their skills are being taught and imitated all over the world by other specialties. One of the their great strength is their conservatism: they know when not to operate. Although in their defense, plastic surgeons do the difficult surgery, many studies document their difficult times with the plaintiff¹s bar (6,7), and moreover, their very high complication and even mortality rate (8). Maybe it¹s not best for dermatologists to perform even limited abdominoplasty: for reasons other than their training. However, if they choose to, then their work should be evaluated on an objective level. Ad hominum attacks on the basis of specialty do not contribute to improved patient care.
You may know that the plastic surgeon organizations are spending over a million dollars a year on advertising their collective superiority. With documentation including the references below, this advertising is now illegal in some states including California, where laws prohibit advertising claims not supported by scientific study.
- Matarasso, Alan, M.D. Liposuction as an Adjunct to a Full Abdominoplasty. Plastic Reconstr Surg 95, 829, 1995. April 1995.
- Goldwyn, Grazer, F.M., R.N. Abdominoplasty Assessed by Survey, with Emphasis on Complications. Plastic Reconstr Surrounding. 1997. April; 59 (4): 513-7.
- Owsley, John Q., M.D., F.A.C.S. Aesthetic Facial Surgery. W.B. Saunders Company, 1993. Page 2.
- Klatsky, Stanley A., M.D. Aesthetic Surgery Journal, November-December 1999. Editorial: Aesthetic Surgical Education, A Personal Perspective.
- Linder, Stewart A., M.D., Mele, Joseph A. III, M.D., Capozzi, Angelo, M.D. Teaching Aesthetic Surgery at the Resident Level. Aesthetic Plastic Surgery Journal 1996; 20:351-354.
- Coleman, W.P., III, M.D. et. al. Does the Location of the Surgery or the Speciality of the Physician Effect Malpractice Claims in Liposuction? Dermatol Surg 25:5. May, 1999.
- Gorney, Mark, M.D. The Wheel of Misfortune: Genesis of Malpractice Claims. Clinics in Plastic Surgery, Vol 26:1. January 1999.
- The Sun Sentinel, investigative newspaper in Florida, found that the vast majority of deaths due to cosmetic surgery in recent years were due to board-certified plastic surgeons. These were a series of articles in 1999 that can be obtained from the sunsentinel.com web site.
- Perkins, Stephen W., M.D. Facial Plastic Times. Vol 20:5, p. 3. June 1999.