February 11, 2007
Cosmetic Surgery’s Risky Move: Tucsonan’s Death After Office Procedure Kindles Concern; ‘Nobody Regulates This’
By Carla McClain, The Arizona Daily Star, Tucson
Feb. 11--Many Tucson plastic surgeons are performing major surgeries using heavy anesthesia in their offices, with no back-up teams for emergencies, little oversight by the state and no record on their safety.
Although few details about the death of Kimberley Taylor, 53, after undergoing two cosmetic surgical procedures Dec. 28 have been confirmed, it is known that her surgery was done by Tucson plastic surgeon Dr. Armando Alfaro in his office surgical suite.
During the surgery, Taylor was under a form of anesthesia known as "conscious sedation," administered by a nurse anesthetist and not a physician anesthesiologist, according to information provided by her family, friends and colleagues.
At some point during the surgery, she stopped breathing and suffered a cardiac arrest. She arrived comatose at Tucson Medical Center's emergency room and was placed on life support. Taylor died 10 days later.
Taylor's colleagues originally reported she was undergoing a tummy tuck and a facelift -- two major cosmetic surgeries. But her mother said the procedures were more minor -- some liposuction around her waist and a tightening of her jaw line.
Arizona does not track patient deaths that occur from out-of-hospital, office-based surgeries, so there is no way to know how often it happens.
But in one state that does keep track -- Florida -- deaths were occurring at 10 times the rate of deaths during similar surgeries in hospitals or outpatient surgery centers.
That forced a statewide crackdown on the office-based surgical suites that are all the rage among plastic and cosmetic surgeons now, with new laws mandating safety standards and regular safety inspections to ensure they are met.
By contrast, most plastic surgeon surgical suites in Tucson remain unlicensed, unregulated and unchecked by Arizona.
It is estimated that 80 percent of Tucson's 28 plastic and cosmetic surgeons now operate their own office-based surgical suites, doing everything from mole removals to face-lifts to tummy tucks. Nationwide, nearly half of all surgeries are now done in doctors' offices, according to the American Society for Aesthetic Plastic Surgery.
Doctors love the privacy they can offer their patients, also the lower fees they can charge and higher profits they make.
"Nobody regulates this. Nobody reports the results. So what's going on out there? Who's doing what?" asked Sue Gerard, director of the Arizona Department of Health Services and a former state legislator.
"Now that more and more invasive procedures are being done in physicians' offices, I definitely think we really need to revisit this issue, for the sake of patient health and safety. We have no idea to this day what is actually happening."
Not wanting to cast aspersions on their colleagues, two Tucson plastic surgeons who still insist on doing all their surgeries in the hospital declined to comment on their reasons.
But even those who now do many or all of their surgeries in their offices admit to the safety advantages of a hospital.
"In a hospital setting, obviously you are in a place with a lot of doctors and nurses to respond" to a life-threatening emergency, said local plastic surgeon Dr. Gwen Maxwell, who recently opened a state-of-the-art surgical facility, where she performs all her procedures. "You just have a lot more people to manage an airway if the patient stops breathing, which can be tricky. You have the blood supplies if the patient is having major bleeding.
"But if you are a surgeon operating in an office who is not comfortable inserting a breathing tube or doing an emergency tracheostomy -- who doesn't do those things often -- and who is not working with an M.D. anesthesiologist, you have a potential problem establishing breathing in an emergency."
Death from cosmetic plastic surgeries remains rare, occurring in one of 57,000 cases, reports the American Society of Plastic Surgeons. About 2 million such surgeries were done in the United States in 2005.
By far, anesthesia during surgery poses the greatest risk, as it does with any surgery, and can cause abnormal heart rhythm, heart attack, stroke, paralysis, blood clots and airway problems. An unexpected allergic reaction, an undetected cardiac problem, certain medications and even herbal supplements, heavy smoking, asthma, and eating before the surgery all can cause life-threatening trouble under anesthesia.
"When a patient stops breathing, you have nine minutes to brain death," said longtime Tucson plastic surgeon Dr. Peter Kay, who performs minor procedures in his office, but major surgeries in an outpatient surgery center. "You have to act very quickly."
Efforts to contact Alfaro -- who has always had an excellent reputation as a plastic surgeon -- were unsuccessful.
"I know that he is just devastated by this," Maxwell said.
The Arizona Medical Board has taken no disciplinary actions against Alfaro in the past five years, the most current records available on the board's Web site show.
Unlike some other local plastic surgeons, he is fully trained in his specialty, has long experience in it, and has a surgical suite accredited by a legitimate private agency that mandates high safety standards -- the same standards now required in highly regulated states such as California and Florida.
In other words, despite the state's lack of oversight, he's followed the rules that should reassure any patient demanding a safe and competent surgeon.
But despite all that, a healthy and fairly young patient died on his watch while undergoing a totally elective surgery that was not medically necessary.
"Dr. Alfaro is one of Tucson's very highly respected plastic surgeons," said Dr. Christopher Maloney, a Tucson plastic surgeon who does most of his major surgeries in an outpatient surgical center, staffed and equipped much like a hospital operating room. "There are a lot of people out there who are not board-certified, and are masquerading as if they are. Alfaro is not one of them."
Patients who are conscientious enough to ask if a doctor is "board-certified" can be fooled easily, Kay said.
"In Arizona, you can say 'I'm board-certified,' but you don't have to say for what, unlike other states that require you to specify," he said. "There are dozens of bogus boards out there -- like the 'board of breast surgery' -- that don't mean anything about your training, only that you've paid $25 to get a piece of paper."
Before the Florida crackdown, doctors with no training in plastic surgery were performing cosmetic procedures in their offices -- ER docs, dermatologists, ophthalmologists, family physicians -- as they still can in Arizona, he said.
With Alfaro's credentials so solid, the bottom-line question is, would Taylor have survived in a hospital?
"Maybe, but we don't know that," Maloney said. "My sense of this is that it is an outlier case, extremely rare, a tragic accident that could happen to anyone, even in a hospital."
However, the case has been compared to one of the most famous cosmetic-surgery deaths in recent years -- that of Olivia Goldsmith, the author of the best-selling novel "First Wives Club," about women whose husbands leave them for younger "trophy" wives, and the resulting obsession with cosmetic surgery to try to compete.
Goldsmith, too, had gold-standard care, at least on paper, for her chin tuck -- one of the top surgeons in New York City at one of the nation's premier specialty hospitals, the Manhattan Eye, Ear and Throat Hospital.
Similar to Taylor, she stopped breathing and suffered cardiac arrest while under anesthesia, went into an irreversible coma, and died a week later, in 2004.
But this was not an unavoidable tragedy. In fact, an investigation by the New York health department found "egregious violations" by the hospital, which was fined the maximum, $20,000. Among the failures were inadequate monitoring of her vital signs while under anesthesia and an ineffective response to the emergency.
The potentially fatal risks of anesthesia are why some Tucson plastic surgeons insist on doing all their surgeries with a board-certified physician anesthesiologist, rather than a nurse anesthetist, even though nurse anesthetists are considered an acceptable standard of care for most types of anesthesia.
And that is where they differ from Alfaro, who used a nurse anesthetist in Taylor's case. Some Tucson plastic surgeons use neither, doing their own anesthesia. That cuts the price for the patient.
"At the end of the day, if you ever have a problem ... you want the best in the city," said Maxwell, who uses only a physician anesthesiologist for surgeries in her office surgery center, which is fully accredited.
"This is surgery. This is not the time to cut corners and try to go cheap."
As Kay, who also works only with a physician anesthesiologist, puts it: "It's just that much more training and security."
However, no one is questioning the credentials of nurse anesthetists to perform anesthesia. It seems to be a matter of comfort with the extra years of training a doctor receives.
"The nurse anesthetists I have worked with have been extremely competent -- they can handle even the most complex heart surgeries," said Tucson anesthesiologist Dr. Brian McCabe. "I really would not say it is more risky. I have tremendous respect for their abilities, especially those with years of experience. They practice at a very high level."
Even so, all surgeries done in Tucson hospitals use physician anesthesiologists. The strict Florida law mandates physician anesthesiologists for all office surgeries requiring deep sedation or general anesthesia -- after finding that less than 15 percent of the office surgery deaths happened under their care.
One of the reasons Arizona's oversight in this area is so lax is that the state licenses and inspects only office-based surgery suites that use general anesthesia. That's the deepest level of anesthesia, and it requires the patient be intubated for breathing. The law was passed some years ago, when the only options were local or general anesthesia.
But today, there is a whole range of techniques known as "conscious sedation," using combinations of tranquilizers and narcotic painkillers to achieve almost the same state of sleep as general anesthesia, but with the patient breathing naturally, without intubation.
Most Tucson plastic surgeons use conscious sedation in their office-based surgeries, as Alfaro did with Taylor, and so do not come under state oversight. And there is no regulation about who should be handling the sedation or anesthesia.
"The law we have in Arizona does not consider these new techniques at all, and we really need to take a look at that," said Lisa Wynn, deputy assistant director of the licensing division in the state health department.
For starters, Arizona health officials will study the tough Florida and California laws regulating office-based surgeries, director Gerard said.
"Regulation is a hassle -- for those being regulated and those doing the regulating," Gerard said. "But this trend is so widespread now, we have to get a handle on it."
Is your surgeon board-certified in plastic surgery? To ensure adequate training, the surgeon must be certified by the American Board of Plastic Surgery. To verify a surgeon's status, contact the board at 1-215-587-9322 or visit www.abplsurg.org
Is your surgeon's surgical facility accredited for safety by one of three recognized accrediting agencies? Those agencies are the American Association for Accreditation of Ambulatory Surgical Facilities, the Joint Commission for Accreditation of Healthcare Organizations, and the Accreditation Association for Ambulatory Health Care. If the facility is accredited, it will be regularly inspected for safety policies and procedures, recovery room, proper use of advanced patient monitoring devices during surgery, proper medical records and patient evaluation, adequate operating-room staff, advanced emergency equipment and emergency response training and procedures, and safe use of anesthesia only by a board-certified physician anesthesiologist or certified registered nurse anesthetist. To verify accreditation status, contact:
--AAAASF at 1-888-545-5222 or www.aaaasf.org
--JCAHO at 1-630-792-5800 or www.jcaho.org
--AAAHC at 1-847-853-6060 or www.aaahc.org
Do surgeons have hospital privileges to perform the same procedure they're performing on you in their offices?
Is your surgeon a member of either the American Society of Plastic Surgeons or the American Society of Aesthetic Plastic Surgery? If so, the surgeon will be required to operate only in a fully accredited facility.
What is your surgeon's plan in the event of an emergency?
Has your surgeon done a complete medical history and physical evaluation of you before surgery?
Is a physician anesthesiologist or a certified registered nurse anesthetist giving and monitoring your anesthesia?
For more detailed safety tips and precautions, go to www.plasticsurgery.org
--Contact reporter Carla McClain at 806-7754 or at [email protected]
Copyright (c) 2007, The Arizona Daily Star, Tucson
Distributed by McClatchy-Tribune Business News.
For reprints, email [email protected], call 800-374-7985 or 847-635-6550, send a fax to 847-635-6968, or write to The Permissions Group Inc., 1247 Milwaukee Ave., Suite 303, Glenview, IL 60025, USA.