In February 1999, physicians in Florida performing office-based procedures were mandated to begin reporting certain events, including immediate and delayed fatalities, and transfer to hospitals. Since the Florida Agency for Health Care Administration began collecting those data, 58 hospital transfers and 19 deaths have been reported.
Twelve (63 percent) of the 19 deaths along with 39 (67 percent) of the 58 transfers to the hospital involved patients undergoing cosmetic surgery. Among the 77 pooled cases of deaths or hospital transfers, 40 (52 percent) were associated with procedures performed under general anesthesia, and all of those were cosmetic surgery procedures. Five deaths plus six transfers were clearly due to anesthesia complications.Plastic surgeons were responsible for 11 (58 percent) of the 19 deaths and 36 (52 percent) of the 58 transfers; facial plastic surgeons contributed another three transfers (5 percents) plus another death (5 percent). There were no deaths involving patients operated on by a dermatologist and only three (5 percent) transfers came from dermatology offices; those involved two patients undergoing skin cancer excision and one case of liposuction under general anesthesia. More deaths and transfers were associated with liposuction than with any other single procedure, and none of those liposuction procedures was performed with tumescent anesthesia, reports Dr. Coldiron, clinical assistant professor of dermatology and otolaryngology, University of Cincinnati Medical Center, Cincinnati.
"The most egregious deaths and injuries and the ones garnering the most publicity are those occurring after cosmetic procedures in the office. It is astounding, but 11(92 percent) of 12 cosmetic surgery deaths and 34 (87 percent) of 39 cosmetic surgery incidents requiring hospital transfer were at the hands of board-certified plastic surgeons, usually operating under general anesthesia provided by anesthesiologists, in accredited offices," Dr. Coldiron says.
"It is the plastic surgeons and anesthesiologists who are filing complaints to state medical boards requesting restrictions on office procedures, and they are the ones killing people. They typically ask the medical board to restrict all procedures except those done under general anesthesia by plastic surgeons. These data demonstrate unbelievable hypocrisy because it is those specialists and their procedures that should be targeted by remedial actions," he comments.
Following the wrong path The data also indicate that proposals to require hospital privileges, board certification and/or office accreditation to perform in-office procedures would have little effect on improving public safety, Dr. Coldiron says. Seven (37 percent) of the 19 deaths were from offices accredited by an independent accrediting agency, as were 35 (60 percent) of the 58 transfers. Sixty-seven physicians were involved in the 77 events; 63 (94 percent) of the physicians were board-certified and 65 (97 percent) had hospital privileges.
Restrictions on dilute local liposuction would be of no benefit, as no injuries or deaths were associated with such procedures. Instead, such restrictions might even backfire, Dr. Coldiron says.
"Limiting dilute local liposuction could drive more patients to liposuction under general anesthesia and expose more individuals to the risks of that procedure," he says.
Measures that would appear to have a positive influence include banning of multiple procedures under general anesthesia, banning of general anesthesia altogether, or banning plastic surgeons from operating in the office, he says.
"Based on the Florida data, those changes would have reduced deaths by 42 to 58 percent and hospital transfers by 20 to 62 percent," Dr. Coldiron says.
Hospital, ASC safety overrated He also pointed out that hospital outpatient surgery departments and ambulatory surgery centers (ASCs) are not required to report delayed deaths or deaths after transfer. The analyses of the in-office surgery data showed deaths were often delayed, with eight (42 percent) of the 19 patients who died expiring several hours to weeks after uneventful discharge or hospital transfer.