Who is rendering cosmetic medical care in the twenty-first century? There is a revolution going on. The availability and popularity of minimally invasive cosmetic procedures has turned nonphysicians into physicians, nonsurgeons into surgeons, and surgeons into cosmeticians. If you don’t believe it, just take a walk through your local yellow pages, read your local newspaper advertisements, or surf the Internet. It is no wonder that prospective patients do not know whom to trust.
There are an estimated 23,000 self-designated cosmetic surgeons in America today and an untold number of other practitioners offering less invasive cosmetic medical services. Several factors encouraged the expansion of cosmetic medicine in recent decades. Rules regarding physician advertising loosened; even mainstream cosmetic surgeons are now able to court their customers directly and do not have to rely on other physicians for referrals.
Provision of cosmetic medical services has become an attractive way to boost income for many physicians. Last but not least, aging baby boomers are leading a wave of increased public demand for cosmetic medical services. Some, although no longer most, cosmetic medical care is rendered by board- certified plastic surgeons.
Of the approximately 5,000 board- certified plastic surgeons in the United States and Canada, most perform both cosmetic and reconstructive procedures. The distinction between cosmetic and reconstructive cosmetic surgery is not rigid, and the techniques learned in one aspect of the specialty are often used to good advantage in other areas.
From a practical standpoint insurance companies are mainly responsible for the push to classify procedures as strictly reconstructive or strictly cosmetic. Until recently, most cosmetic surgery was performed by plastic surgeons, partly as a natural outgrowth of our training to solve physical defects of form and coverage, regardless of location on the body, and partly out of an attempt by plastic surgeons to rescue cosmetic surgery from back rooms and beauty shops.
The efforts by military doctors in World War I to find ways to treat war injuries gave birth to the formal specialty of cosmetic surgery, which has roots in older specialties such as otolaryngology, general surgery, ophthalmology, and dentistry. cosmetic surgery remains the only specialty whose members are trained to perform cosmetic procedures on all body areas.
Perhaps for this reason, the public today still equates cosmetic surgery with cosmetic surgery rather than with dramatic reconstructions. Many surgeons (and others) find a cosmetic practice appealing, for obvious reasons: The hours are predictable, most patients are healthy, the stress is low compared to other types of medical practice, and the pay is very good. Even though most doctors still find rewards in taking care of sick and injured people, many surgeons from various specialties have increased their volume of cosmetic cases in recent years at least in part owing to the following specific circumstances:
The volume of reconstructive cases in most cosmetic surgery practices has gradually but steadily lessened. Skin cancer reconstructions in ever-younger patients may be the only category that is expanding. Legislation mandating seat belts, air bags, lower speed limits, and stiffer drunk-driving penalties has reduced the rates of severe facial trauma.
Burn centers and other specialized tertiary treatment facilities have taken patients with certain complex problems out of the care of community surgeons; lower birthrates have led to a drop in the prevalence of cleft lips and palates; technological developments have allowed many large wounds to be treated effectively without major reconstructive surgery; and numerous procedures that were developed by plastic surgeons have been incorporated into the training and practice of physicians in other specialties.
As a result, larger than ever numbers of plastic surgeons report that cosmetic surgery composes more than half their workload. In geographic areas oversaturated with physicians or where insurance panels are closed to new doctors, cosmetic surgery may be what keeps some surgeons in business. Similar shifts are occurring in other specialties.
As people stop smoking, the rates of head and neck cancers have gone down; antibiotics help patients avoid surgery by treating sinus and ear infections and tonsillitis; allergists and audiologists have taken over the care of many patients with allergy and hearing problems.
These changes have all reduced patient and surgical case volume for otolaryngologists (also called ear, nose, and throat [ENT] or head and neck surgeons), some of whom have started to perform more cosmetic procedures. Dermatology has incorporated progressively greater amounts of cosmetic surgery into its training programs to the point of facing a manpower crisis for nonsurgical dermatologists.
Likewise, ophthalmologists who had devoted substantial portions of their practices to the performance of LASIK operations face declining fees and stiffer competition for these patients, and some have increased their volume of cosmetic surgery procedures to compensate.
Insurance reimbursement for reconstructive procedures has declined dramatically.
Medical practice overhead expenses have skyrocketed in recent years, mainly because of repeated double-digit malpractice insurance premium rate hikes (the typical surgeon’s annual premium has doubled or tripled over the past decade and is now in excess of $50,000). By shifting to an office-based cosmetic practice physicians in some states avoid paying malpractice insurance premiums altogether.
The demand for cosmetic surgery and other procedures has increased such that even busy surgeons doing little cosmetic work regularly receive calls from patients requesting cosmetic procedures.
Physicians from surgical specialties not known for their expertise in cosmetic procedures are among the many taking weekend courses, attending seminars, and meeting with sales reps with the goal of incorporating cosmetic procedures into their repertoire. The big boom in cosmetic medical products and minimally invasive procedures has encouraged nonsurgeon physicians to join the gold rush and add these goods and services to their practices.
One cosmetic surgeon reported that he knew personally of a pathologist (one trained to do tissue and postmortem examinations) doing cosmetic procedures, despite never having examined a live patient in practice until he retired to a Sun Belt state. Not to be left behind, nonphysician wheelers and dealers set up clinics and spas, hire medical directors, and sell cosmetic services to whomever they can entice across their thresholds.
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