Cosmetic surgery's ugly side - June 13, 1998
Concerns are escalating with the demand for nips and tucks
By Robin Harvey
Toronto Star Staff Reporter
Sandra Ciuffreda remembers praying that cosmetic surgery would be a solution to her life-long battle with obesity.
Ciuffreda, who weighed 285 pounds, hoped the La Fontaine Cosmetic Surgery Centre would do what years of diets and stomach ``stapling'' had not.
The clinic helped her get a $10,000 loan for the surgery and in October, 1997, she had 18 litres of fat sucked from her body. She was sent home just hours later, weak and disoriented.
``I was in such pain,'' says Ciuffreda, 31. And when she took off the bandages, ``there was this huge open wound underneath.'' Today, she has an inch-wide, 10-inch-long scar.
Statistics show that in the past five years there has been a marked increase in the amount of cosmetic surgery done in North America, most of it on women.
An estimated 163,950 people had liposuction in Canada and the United States in 1997 - a 215 per cent increase from 1992.
At least 27 private cosmetic surgery clinics now operate in the Greater Toronto Area, many of which have opened in the past five to 10 years.
Thousands of men and women each year seek the medical solution to changing their appearance and walk away happy and satisfied.
Statistics show that about one in five is a repeat patient and two in five have multiple procedures at the same time.
But the growth in popularity of cosmetic surgery has created problems. Concerns are being raised about doctor training, a lack of regulations, possibly dangerous procedures and hard-sell marketing techniques.
In Ontario, any medical doctor can say they do forms of
cosmetic surgery as long as they feel they are qualified. But the work they perform may not always be related to their area of specialty training. Forms of cosmetic surgery have been practised by family physicians, dermatologists, ear, nose and throat specialists, general surgeons, ophthalmologists, gynecologists and even a pathologist.
There are very few regulations safeguarding the public at private cosmetic surgery clinics. Veterinary clinics and funeral homes have more specific standards.
There is virtually no university-based training in Canada in the growing field of cosmetic laser surgery.
In at least one cosmetic surgery clinic, lay people are injecting patients, diagnosing conditions, recommending treatment and fitting implants. This is legal because in Ontario a doctor can delegate anyone to do many medical procedures, known as controlled acts, under his or her supervision.
In the past two years there have been more than 100 deaths from liposuction in the United States, doctors at a recent conference were told. It isn't know whether any have occurred in Canada.
Some physicians in the Greater Toronto Area are taking out more than 30 pounds of fat in some cases - amounts that are considered dangerous and even life-threatening - and then sending patients home unmonitored, several doctors say.
Malpractice lawyer Jerry Levitan says some cosmetic surgery doctors will do surgery ``on anybody.'' Other lawyers concur. Levitan says he knows of one woman who was obviously psychotic and incapable of making rational decisions and yet received cosmetic surgery. Another lawyer, Tom David, tells of a teenager who had liposuction even though she was slender.
Doctors often use hard-sell techniques to get patients to agree to surgery. In some cases, patients report they were promised impossible results and ``no-risk'' surgery. One woman in her 50s says a doctor called her at home several times to persuade her to have surgery. On the day of the procedure, she got a consent form citing the risk of death, but was told to ignore it because it was ``only a formality.''
Some clinics offer on-the-spot financing. Interest can be 20%
In brochures and ads, and on Internet sites, many doctors have what seems to be misleading information about their experience, credentials and the nature of cosmetic surgery. Some appear to break advertising rules of the College of Physicians and Surgeons of Ontario.
Some clinics offer on-the-spot financing, arranged with the help of clinic staff. Interest rates can be 20 per cent, or more. Some finance companies even charge the doctors a percentage of the loan.
Ciuffreda is suing the doctor, general surgeon Alvin Anderson, and the clinic.
In his statement of defence, Anderson acknowledges that further surgery was required to achieve the desired results in Ciuffreda's case. He says he was willing to perform this extra surgery for free.
However, he says, because Ciuffreda and the clinic could not agree on a fee for the clinic for the additional work, he was ``denied permission to use the clinic facilities for the subsequent surgery.''
Ciuffreda says she is speaking out because she thinks more people need to be aware of what can go wrong during cosmetic surgery.
In Ontario, purely cosmetic surgery, which includes procedures such as liposuction, face lifts, eyelid lifts and breast augmentation, is most often performed at private clinics and is not covered by the Ontario Health Insurance Plan.
While the clinics themselves are not government-regulated, the doctors who work in them are governed by the College of Physicians and Surgeons.
``There are doctors working in these clinics and they are accountable to the college,'' spokesperson Jim Maclean says. ``We do very much care about any breach of regulations.''
At its upcoming council meeting, the college will look at the possibility of regulating private clinics, including private cosmetic surgery clinics. It will also discuss the delegation of medical acts and likely recommend they, too, be regulated, Maclean says.
The college has long been concerned about standards at private surgery clinics.
In 1995, a college brief to the health ministry stated, ``A large and growing out-of-hospital component of medical practice is not subjected to any formalized accountability for quality of care . . .''
With regard to private surgery and diagnostic clinics, including cosmetic surgery clinics, the college brief notes, ``We have no idea how many there are, where they are located, who is working in them, or precisely what they are doing.''
Many doctors are concerned about the emerging problems.
Some, like Bernd Neu, a past president of the Ontario Society of Plastic Surgeons, say cosmetic surgery standards in the Toronto area are ``excellent.''
``But there is a fringe group (of doctors) who are performing surgery that is well beyond their professional training, especially when a service is done at a private clinic,'' he says.
Dr. James Mahoney, plastic surgery chief at St. Michael's Hospital, says cosmetic surgery is too often fraught with ``flash . . . driven at a market level instead of a professional level, (which is) not good for patients.''
There is big money to be made from cosmetic surgery - it operates outside OHIP and doctors can set their own fees, according to physicians including Dr. Stephen Mulholland, director of cosmetic plastic surgery at the SpaMedica clinic.
Family practitioner Dr. Andrew Sarne once operated a vasectomy clinic and then went into foot medicine. He says he went into cosmetic surgery, opening his clinic six years ago, ``to get out of OHIP'' and escape the public system, which he says has been hurt by government cuts.
`She wanted to call an ambulance, but they wouldn't let her'
Some doctors fear this rapidly growing market may result in tragedy.
``There will probably be (a death in Greater Toronto) soon,'' says Dr. Robert Stubbs, of the Cosmetic Surgicentre in Yorkville.
``It's surgery on demand to the public right now. They can walk into any doctor's office and plunk down the money and get what they want.''
One doctor, who asked that his name not be used because of patient confidentiality, says a woman he treated 12 weeks ago for complications ``could have died'' after liposuction by another doctor at a downtown clinic.
The woman bled profusely, he says. Eventually, she needed blood transfusions and now has permanent damage to her legs, he says.
``She wanted to call an ambulance, but they wouldn't let her,'' the doctor said.
He says he fears someone might die from botched cosmetic surgery. The College of Physicians and Surgeons has been made aware of the case, he says.
In a review of lawsuits in the cosmetic surgery business, which contain allegations that have not been proven in court, The Star found:
A woman in her 50s who claims she has a disfigured brow and nose, obstructed breathing, and loss of the ability to smile, smell and close her eyes properly after a facelift and eyelid and nose surgery in November, 1993. The surgery was done by Dr. Lorne Tarshis, who denies the charges and says the woman has ``psychological problems.'' He says he was careful, competent and diligent and informed her about all the surgery involved, including any complications. If she has sustained any injuries, they are not attributable to any action by him, he says.
A woman in her 50s was admitted to hospital with pulmonary embolism days after having a tummy tuck and liposuction. Her wound became severely infected. The woman claims she had complained to her doctor, Toronto plastic surgeon Michael Bederman, but was told nothing was seriously wrong. She spent many months recovering. Bederman has denied the charges in court documents and says the woman did not participate in follow-up care and refused to go to hospital when he suggested it. He also says her wound was not infected and another doctor who saw her after she went to hospital said she was much improved.
A woman who had a chemical acid peel to make her forearms look younger developed thick, red scars that, she says, continue to cause her pain years later. A week after the arm peel, the woman had a thigh lift and leg liposuction and her legs became severely infected, requiring 3 1/2 weeks in hospital. Bederman also did this surgery and denies the charges in court documents. He says she did not participate in proper follow-up care or take antibiotics before her surgery as he requested. He says he did everything properly in caring for the woman, but she was very unco-operative.
A man in his 30s claims his penis has become deformed and scarred after undergoing a penis-lengthening operation in 1994. He had to wear weights on his penis for almost a year, but claims he was never told before surgery that it was routine practice. Dr. Robert Stubbs, who performed the surgery, denies the charges and says the man neglected to give him a complete medical history before the operation. He says he told the man of all possible complications, that healing would take time and that the procedure at that time was still considered experimental.
A woman, Tracy Hynes, says her lips swelled and became disfigured for weeks after she had what she believes was a silicone-based substance to enlarge her lips injected at the La Fontaine Clinic on Yonge St. The clinic has denied her claims and countersued for $7 million, alleging she conspired with an unnamed doctor to harass the clinic and put it out of business.
Doctor says patients often have unrealistic expectations
Dr. Tom Bell, president of the Canadian Society for Aesthetic (Cosmetic) Plastic Surgery, says taking 18 or 20 litres of fat from any obese person, like Ciuffreda, can be ``dangerous'' - especially at a single session. Liposuction is definitely not for weight loss, he says.
Obese people have a greater risk for cardiovascular, breathing and other complications, and should never undergo such major procedures on an outpatient basis, he says.
Mulholland, of the SpaMedica clinic, says he is very concerned about the ``mega-volume'' liposuctions being done on an outpatient basis, such as what was done on Ciuffreda.
Mulholland, Neu and other doctors are also concerned that some doctors are not always using anesthesiologists when they should be.
Bederman says the hardest part of his job is screening out people so set on surgery that they ignore the risks or lie about their medical history. Often patients have unrealistic expectations and end up unhappy, he says.
Some doctors strongly disagree with clinics getting involved in financing.
Neu and Mahoney think it's inappropriate to give people loans for thousands of dollars of elective surgery.
``You are looking at interest rates in some cases of in excess of 20 per cent,'' Mahoney says.
Ciuffreda says borrowing $10,000 for surgery clouded her judgment.
``Being on the hook for the money and ready for surgery, you don't want to back out,'' she says. ``I wish I had.''