Propofol found in Weston Medi Spa patient

New details have now emerged regarding the tragedy which occurred in south Florida, following liposuction surgery at an unlicensed medispa, which we discussed in an earlier chapter of the blog (here).

According to an October 30, 2009 article in the Sun-Sentinel (here), the patient was not having the liposuction surgery performed with just local anesthesia (numbing with lidocaine), but she also was given the anesthesia drug Propofol for intravenous sedation. Propofol is a safe drug in the trained hands of an anesthesiologist, but, as Michael Jackson found out, it can be lethal in the hands of an amateur.

This discovery makes a huge legal and regulatory difference. It's giving anesthesia without a trained anesthesiologist or nurse-anesthetist being present.

Receiving any sort of intravenous sedation automatically defines the procedure, according to existing Florida regulations, as a "level II office surgery" at a minimum. The level II category mandates significantly more stringent requirements than a procedure performed with local anesthesia only, such as:
- a well-defined list of safety equipment present in the office
- certain monitoring standards for the patient's vital signs and oxygenation
- completion of inspection of the surgery center by either the State of Florida or one of the national accreditation agencies
- hospital privileges for the surgeon
- a standing hospital transfer agreement in case of emergency.

None of these regulations were being followed by the Weston Medi-spa. The physician who performed this surgery was not board-certified in a surgical specialty, and reportedly did not have hospital privileges to perform liposuction in any hospital.

The Board of Medicine is now looking at a new rule, which would require all Medi Spas where surgical procedures are performed to follow the same regulations as surgery centers. I think this is an excellent idea, that would enhance patient safety.

However, these rules have to have some "teeth". It's one thing to write a good law, but another thing altogether to insure that the law is followed. Currently, it is the enforcement of existing regulations that is lacking. There are some good people working for the Board of Medicine - but they are stretched thin, in terms of manpower and funding.

Do longer surgeries have a higher complication rate?

A common question around here from patients is whether they can combine surgeries - say, a tummy tuck with a breast operation.

To answer this, we have to look at things from 2 different angles:
1) legal - what do the Florida regulations permit, and
2) medical - what do the studies looking at surgical complications find.

First of all, the applicable Florida regulations for office-based surgery state that the "maximum combined duration of anesthesia shall not exceed 8 hours."
Longer procedures can be performed - in a hospital.

From the medical literature, the answer to the question relating complication rates and duration of surgery is, surprisingly, somewhat of a mixed picture, when it comes to plastic surgery operations for healthy people.

Data against long surgeries:

- increased overall complication rates with longer anesthesia / surgery times in multiple studies in the anesthesia, cardiac surgery, orthopedic surgery, and urology literature. In particular, the study from the British Journal of Urology found a fourfold increase in non-urologic complications with anesthesia durations > 6 hours.

- increased rate of DVT (deep vein thrombosis) and pulmonary embolism. For example, in one orthopedic study, these potentially life-threatening complications were 3.5 times more likely when the anesthesia duration exceeded 3.5 hours for hip or knee replacement surgery, which are infamous for high rates of DVT's.

- increased pulmonary complications with anesthesia times greater than 2.5 hours, in both normal patients, and especially in those with pre-existing chronic lung conditions.

- increased rate of surgical site (wound) infections with longer surgeries.


Data supporting combination surgeries

- no increased risk seen when facial surgery operations were combined, in a study performed at Yale University. Anesthesia / surgery duration was not associated with increased risk in this study when surgeries under 4 hours and over 4 hours were compared.

- no increase in the complication rate when aesthetic tummy and breast operations were combined in a study from a private clinic in California. However, in this study, all surgeries were less than 6 hours in length.

The bottom line: Combination surgeries can be performed safely, but that doesn't mean we should throw caution to the winds and have a marathon surgical make-over. Despite our best efforts at prevention & prophylaxis, DVT, pulmonary embolism and pulmonary complications of anesthesia are lingering issues related to longer surgeries with general anesthesia. And when these problems occur, they can be devastating.

I do not typically recommend combinations of surgery exceeding 6-7 hours of planned surgery time, even for healthy patients. I feel it is safer to divide up the surgery into two stages, if the length of surgery exceeds this number.

So, going back to the original question: I will combine a breast augmentation (approx. 1 hour procedure) with a major abdominoplasty (3-4 hours). But I will not generally combine a major breast reduction or complex mastopexy (3-4 hours) with a big tummy tuck, as I feel the lengthy anesthesia / surgery time is worrisome.

As always - safety first.

Double-Board Certified Plastic Surgeon?

Some doctors are calling themselves "double-board certified" or "triple board certified" surgeons. This terminology seems to be especially common on the Internet, and, in my opinion, is a bit of a pretentious marketing ploy. Since the whole board certification thing can be a bit confusing for consumers, let's talk about it.

As you probably already know, being board-certified in a specialty means you've completed an approved residency in that area, then completed the written and oral examination process set up by that Board, including case reviews and time-in-practice requirements. It's a thorough method - and anyone who passes any of the board exams of the American Board of Medical Specialties (ABMS) should be proud to call themselves a specialist in that area.

A physician who has completed training and passed the board examinations in two different areas of surgery or medicine can legitimately call themselves "double-board certified", if they wish. For example, many plastic surgeons, including myself, have trained in General Surgery, as well as Plastic Surgery, and have completed both examination processes. A background in Otolaryngology (ear, nose & throat) as well as Plastic Surgery is another common combination. Parenthetically, I don't know anybody who leaves Plastic Surgery to go into ENT - it's always the other way around!

In addition to the American Board of Plastic Surgery (ABPS), the Royal College of Physicians and Surgeons of Canada also has a very rigorous examination process in Plastic Surgery, and their certification is widely accepted in the U.S. as being completely equivalent in quality to the ABPS' process. Other than Canada, medical training diplomas and certificates from other countries are not commonly accepted here.

What makes matters more confusing for consumers, though, are the plethora on non-ABMS organizations, that call themselves "Boards" of this or that. They are not part of the official group of 24 medical and surgical specialties that make up the ABMS, and are not generally considered as being equivalent to an ABMS certification by the majority of States in the U.S. (You can read more about this at the ABMS website - www.abms.org)

For example: You or I could quite legally start up our own corporate organization, and call it, say, the "American Board of Blogging". We could then issue certificates to our friends which proclaim that so-and-so is "board-certified" by the American Board of Blogging. And we could have meetings, and give courses about blogging from our affiliated "American Institute of Advanced Blogging".... but, of course, our fictional American Board of Blogging wouldn't be any kind of officially-sanctioned ABMS Board. Except for one loophole - if we can somehow persuade our State legislators to pass a law to make us legally "equivalent" to those other Boards.

Well, here in Florida, certifications by the non-ABMS "American Board of Liposuction", the "American Board of Laser Surgery" or the "American Board of Cosmetic Surgery" are not legally considered by the State of Florida as being equivalent to certification by the American Board of Plastic Surgery, which is the one-and-only official ABMS board which certifies Plastic Surgeons.

However, the State of Florida does recognize the American Board of Facial Plastic Surgery (ABFPS). So, if you are having surgery above the collarbone , you can choose between an ABFPS surgeon and an ABPS surgeon. The major difference between Plastic Surgeons and Facial Plastic Surgeons is, of course, that Plastic Surgeons are trained to do both reconstructive and cosmetic types of surgeries from head to toe. Facial Plastic Surgeons are not - they are limited to the head and neck, and don't receive any training in breast surgery or body contouring, for example. So, I wouldn't recommend a Facial Plastic guy to do your breast augmentation, but they may be a reasonable choice for a rhinoplasty.

One last note for today: the "Truth in Medical Education" law here in Florida means that, if a physician claims to be board-certified, he must tell you what Board gave him his certification. For example, if you find out that your so-called "cosmetic surgeon" is only certified by the American Board of Psychiatry, you may wish to reconsider having him or her do that liposuction!