Image for sale: Plastic surgery in America

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Plastic surgery is becoming a fixture of American life.

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BY MARGARET ANN MIILLE

Appearances count in King's professional world.The 60-year-old Realtor for Coldwell Banker at St. Armands Circle thinks she needs to look youthful and energetic when she approaches prospective home buyers willing to spend up to $3 million.That's partly why, a year ago, she went to a plastic surgeon to have her face smoothed and decades of sun damage zapped with a laser. She gets Botox injections every four months, mostly to ease her migraines, she says. Eventually, she'll get a face lift.

King likens her ongoing physical makeover to trading up for a new car."It was appropriate for me to freshen up the look. I'm not going to drive around in a 1995 Cadillac when it's 2003."More than 6.5 million people had a doctor alter their appearances in 2002, according to the American Society of Plastic Surgeons. That was a 12 percent drop from the previous year, which came as no surprise with a sagging economy and waning consumer confidence.

But surgical cosmetic procedures remained stable despite the overall decline. More than 1.6 million people went under the knife in 2002, a 1 percent increase.Nonsurgical cosmetic procedures, which involve lasers, chemical solutions and a variety of injections, fell 15 percent during the same period. However, such procedures were clearly the most popular option, being chosen by 4.9 million Americans last year.Though the number has declined nationally, many Southwest Florida plastic surgeons say that trend doesn't hold true here. And, with a graying population and a batch of new products on the horizon, they say demand will continue to increase.

Location helps. Florida trails only Washington, D.C., in having the highest ratio of plastic surgeons to residents, the ASPS said.Another contributing factor is the fading stigma about being cosmetically altered. Consumers across economic lines are finding the means to fork over hundreds or thousands of dollars for physical rejuvenation, with the number of teenagers, men and seniors on the rise.The widespread availability of cosmetic surgeries and procedures does raise some concerns. Some doctors in unrelated fields are entering the lucrative plastic surgery business with no more experience than a crash course from a manufacturer.

Botched outcomes hurt patients and taint the industry's reputation."The marginal results that people with minimal training can obtain can denigrate the entire profession," said Strausser, a plastic surgeon and Sarasota Memorial Hospital's chief of staff. "It's not breaking the law; it's just breaking the public trust."

A growing trend

Shaving years off the face and resculpting the body are becoming an American way of life, and the procedures are expected to become more commonplace as baby boomers near retirement.Last year, people 35 to 50 years old represented nearly half of all people choosing cosmetic plastic surgery.Most were women -- 5.6 million compared with less than 1 million men.In 2002, the top five cosmetic surgeries were nose reshaping, liposuction, breast enlargement, eyelid surgery and face lifts, the association said.

Botox soared to the top of the list of nonsurgical cosmetic procedures. Since the U.S. Food and Drug Administration approved it for cosmetic use in April 2002, more than 1.1 million people have had the toxins shot into their crow's feet and frown lines.Other popular procedures include chemical peels; microdermabrasion, which involves "sanding" the skin with tiny rough particles; laser hair removal; and sclerotherapy, a treatment to minimize the appearance of spider veins.

Some industry experts liken getting a Botox shot or a minitummy tuck nowadays to getting a massage or a manicure. In an uncertain economy, they say, it provides a cheaper pick-me-up than a face lift.The push for the treatments in Southwest Florida hasn't eclipsed plastic surgery itself, but some surgeons have eliminated the reconstructive side of their business to focus solely on cosmetics."I do think there are a lot of people getting smaller procedures, but we do as many or more face lifts as we did two years ago," said Jasin, a facial plastic surgeon at the Jasin Facial Rejuvenation Institute in Longboat Key and Tampa.

Jasin performed King's transformation and is one of 150 doctors nationwide chosen to train other doctors to use Botox."What we've found over the years is people want less invasive procedures and are willing to accept a little less change," he said. "It's really a healthy attitude. A realistic goal is to improve a person's appearance, and not to make them as near as perfect as we can make them. It allows them to look more natural."While Botox injections remain high in demand at Jasin's offices, another popular procedure is the neck lift, or submentoplasty. An incision is made under the chin, fat is removed and a muscle is tightened.

It's less invasive than a full face lift, formerly the most common way to tighten sagging neck tissue that causes a less defined chin and jawline. Submentoplasty can be done alone or combined with other procedures, such as chin augmentation, laser resurfacing, eyelid surgery and facial liposuction.In addition, Jasin provides a variety of skin care services, such as peels, facials and full-body treatments. He also offers cosmetic travel packages with stays at The Colony Beach & Tennis Resort on Longboat Key and The Resort at Longboat Key Club.

While his patients, on the average, range from 60 to 70, he also treats people in their 80s.So does Issa F. Baroudi, a plastic surgeon who has captured about 90 percent of Charlotte County's business. His oldest patient was a 90-year-old woman celebrating her birthday in March by having her cheeks and neck lifted and her upper lip dermabrased."Chronological age is really nothing," said Baroudi, as long as seniors maintain good general health. He turns away those who aren't promising candidates, such as people with multiple systemic problems, including kidney disease, or stubborn bad habits like smoking.

About half of Baroudi's business is devoted to reconstructive surgery, much of it related to cancer. His volume of cosmetic procedures has risen since he moved his practice last fall to the Baroudi Cosmetic and Plastic Surgery Center in Port Charlotte.Half of the 15,000-square-foot building is devoted to his ambulatory surgery site, the Promenades Surgery Center.Other surgeries done by Baroudi include face lifts, liposuction, breast augmentation, breast reduction, eyelid and brow lifts and nose and ear reshaping. The nonsurgical variety involve injecting Botox, treating spider veins and filling lips with fat or collagen.

Some of his patients span generations of families who share such traits as protruding ears or a tendency to develop cancer.

Some not formally trained

Enrique J. Fernandez, past president of the Florida Society of Plastic Surgeons, has seen his profession evolve considerably in the 17 years since he opened his solo Bradenton practice."Plastic surgery is rather unique, in that a significant number of people who are not formally trained in plastic surgery are doing plastic surgery procedures all the time," he said. "When you get your Florida license, you can basically practice whatever you want to practice. That system has been in place for many, many decades."

That lament is shared by Strausser, the Sarasota plastic surgeon."We have a lot of quacks out there who call themselves plastic surgeons," Strausser said, referring to other medical specialists, including gynecologists, oral surgeons and ophthalmologists, who advertise that they perform plastic surgery. But they lack the training, Strausser said."It's become a 'caveat emptor,' a buyer-beware situation."You don't have to be a plastic surgeon to administer Botox, but it takes one, or a dermatologist, to understand the facial muscles and recognize when something goes wrong. A mis-aimed shot can mean the difference between an unfurrowed brow and an eye that temporarily droops.

Nuland, general counsel in ville for the Florida Society of Plastic Surgeons and the Florida Society of Dermatology and Dermatologic Surgery, said great strides have been made within the last five years in strengthening the "Office Surgery Rule."The rule, enacted by the state Board of Medicine, mandates safety and staffing requirements for all doctors who perform surgeries at their practices, not just plastic surgeons. Improvements made include stricter standards for equipment, staffing and certain types of procedures.

For example, there are limits now on how much fat can be removed during liposuction.Also relevant to the industry is the "TIME" bill, or Truth In Medical Education. Introduced to the Florida Legislature this year, it would require doctors not only to inform patients of their training but to specify which board certifies them. There are plenty of sham boards out there, and the disclosure bill is intended to help consumers determine which are reputable and relevant to their procedures.

The TIME bill never made it further than a committee hearing. But Nuland said he's encouraged by another bill proposed by Gov. Jeb Bush that would authorize a study on what information patients should have to make informed health care decisions.If it doesn't pass in the special session June 16-19, Nuland said, there are plans to reintroduce the TIME bill during the 2004 regular legislative session."We tell everybody to check the credentials of your plastic surgeon," Nuland said. "We want legislation that would make this disclosure mandatory."

According to the ASPS, Florida has 319 plastic surgeons for 12.94 million residents, a ratio of 1 per 40,558 -- second-highest in the nation."I'm surprised it's not No. 1," said Dr. Leikensohn, who has plastic surgery practices in Sarasota and Bradenton. "Everyone thinks it's California, but it's not."Leikensohn performs a variety of plastic surgeries and procedures, including facial and breast lifts and body contouring, which includes lipsuction, thigh lifts and tummy tucks.

Most popular among the boomers, he said, are mini face lifts and brow lifts.His patients run the gamut from retirees who want to look youthful as they rejoin the work force to teenage boys who need surgery because of a condition that causes enlarged breasts."People come to see me because the bottom line is that what they see on the outside doesn't match the inside," Leikensohn said.

New work on the horizon

Ellen Sullivan, a Tampa insurance agent and another one of Jasin's patients, decided for her 50th birthday to give herself a new face to match her slimmer body. She had lost 50 pounds.With $11,000 withdrawn from her 401(k) savings, she got a chin implant and had her face, neck and eyelids lifted in late April."I thought it was vanity to begin with. I never thought I'd have the whole gamut done," said Sullivan.One thing led to another after Sullivan saw the possibilities in computer generated before-and-after pictures. She's pleased with the results, which she says aren't so dramatic that it's obvious she has had the work done.

In speaking with friends, she was surprised to learn that many had gone the same route.Plastic surgery may not be a recession-proof industry, but it comes close."When times are good, people have spare money and they spend it on themselves," said Leroy Young, a St. Louis plastic surgeon and spokesman for the American Society of Aesthetic Plastic Surgery. "When they are down and out, they want to do something to feel better."A slew of newer procedures and products include gluteal augmentation, or buttock implants, and contouring to balance upper and lower body proportions. Another is Thermage, a procedure that uses radio waves to tighten facial skin, complementing face and brow lifts.

Then there's CoApt, a device that helps doctors hold eyebrows in place while they lift them, and Wrinkle Relax, a kind of topical Botox.The biggest wave hitting the American market is injectable fillers. Some are FDA approved, but only for certain procedures. Artefill, for example, can be used for wrinkles but not for plumping up lips. Others, such as Restalyne, are being tested in clinical trials, but are already used extensively in Europe and Canada.

Some Americans can't wait until these products are available on the national market."There is so much demand for these new products that people try to get them from outside the country and bring them in," Young said. "It's a cottage industry."