Cosmetic tourism for breast augmentation: a systematic review

Developing an International Framework for Informed Consent in Plastic Surgery: A Focus on Cosmetic Breast Augmentation

Background

Informed consent is a fundamental pillar of patient rights and is an essential part of good clinical practice. In 2019, the International Confederation of Plastic Surgery Societies launched a survey to collect feedback on informed consent practices, with an aim to develop an international guideline for cosmetic surgery.

Methods

A 15-question survey was sent to delegates of the International Confederation of Plastic Surgery Societies for dissemination to their national society members. The survey comprised a range of quantitative and qualitative questions. Descriptive and thematic analysis was performed.

Results

There were 364 respondents. Over half of the respondents reported no local informed consent policy, whereas others noted national society, specialist college, or government policies. The majority of respondents believed that the performing surgeon should be responsible for obtaining informed consent with at least two face-to-face consultations. Most respondents agreed with a cooling-off period (duration based on procedure type and use of high-risk devices). Regarding cosmetic breast augmentation, the majority of respondents felt that the performing surgeon should be responsible for postoperative management, including cases that occur as part of surgical tourism. Some respondents incorporate financial consent as part of their informed consent practice. Most supported the development of an international informed consent guideline.

Conclusions

Informed consent should result from face-to-face consultations with the performing surgeon. There should be a minimum cooling-off period. Postoperative surveillance should be available in all settings. The findings of this survey will help inform an international standardized informed consent guideline for cosmetic surgery.

Evaluating Chatbot Efficacy for Answering Frequently Asked Questions in Plastic Surgery: A ChatGPT Case Study Focused on Breast Augmentation

BACKGROUND

The integration of artificial intelligence (AI) and machine learning (ML) technologies into healthcare is transforming patient-practitioner interaction and could offer an additional platform for patient education and support.

OBJECTIVES

This study investigated whether ChatGPT-4 could provide safe and up-to-date medical information about breast augmentation that is comparable to other patient information sources.

METHODS

ChatGPT-4 was asked to generate 6 commonly asked questions regarding breast augmentation and respond to them. Its responses were qualitatively evaluated by a panel of specialist plastic and reconstructive surgeons and reconciled with a literature search of 2 large medical databases for accuracy, informativeness, and accessibility.

RESULTS

ChatGPT-4 provided well-structured, grammatically accurate, and comprehensive responses to the questions posed; however, it was limited in providing personalized advice and sometimes generated inappropriate or outdated references. ChatGPT consistently encouraged engagement with a specialist for specific information.

CONCLUSIONS

Although ChatGPT-4 showed promise as an adjunct tool in patient education regarding breast augmentation, there are areas requiring improvement. Additional advancements and software engineering are needed to enhance the reliability and applicability of AI-driven chatbots in patient education and support systems.

Complications arising from aesthetic surgery procedures in foreign countries and Switzerland

BACKGROUND

Cosmetic surgery tourism has increased in popularity in recent years, with arising complications and post-operative follow-up care often managed in the client's home country, thereby burdening the Swiss health care system.

METHODS

We retrospectively reviewed patients with complications after cosmetic surgeries abroad and in Switzerland who were treated at the University Hospital Zurich between 2015 and 2019. Data were collected from medical records and reviewed for patient characteristics, procedures, complications, and treatment modalities.

RESULTS

A total of 228 patients (207 females and 21 males) were identified with female mean age of 40.9±12.0 years and male mean age of 34.3±8.9 years. Most complications were observed for procedures performed in Europe (69%) with only thirty-six patients (16%) experiencing complications due to a procedure undertaken in Switzerland. Breast surgery was the most frequently performed procedure (60%), followed by body contouring (17%) and facial surgery (12%). The most common complications occurring after surgeries abroad were pain and discomfort (19%) as well as aesthetic dissatisfaction (18%), followed by wound breakdown (14%) and infection (11%). Most patients (76%) were treated as outpatients and the treatment of all patients over the observed period cost the healthcare system $ 795,574.

CONCLUSIONS

There is an ongoing trend of cosmetic surgery tourism leading to an increasing number of patients with complications requiring aftercare in Switzerland. In contrast to previous research, more men are seeking cosmetic surgery abroad and the most common complications, such as wound healing disorders and infection, descreased in favor of aethetic dissatisfaction, possibly indicating ameliorated patient aftercare abroad.

The financial burden of complications of overseas breast implants at the Royal Brisbane and Women’s Hospital

Background: An increasing number of Australians are travelling overseas for aesthetic surgery. This study aims to establish the financial costs of complications arising from overseas inserted implants. Method: Data from the Australian Breast Device Registry (ABDR) on patients who have undergone remov-al of overseas inserted implants at the Royal Brisbane and Women’s Hospital from October 2014 to Octo-ber 2019 was analysed. Financial costs were calculated using electronic medical records and discharge codes. Results: Of the 331 cases of implant removals recorded, only eight (2.4%) were from overseas inserted de-vices. Seven of these were performed as emergency procedures. Two patients required more than one op-eration. Length of stay (LOS) ranged from two to 28 days with a median LOS of 8.6 days. Most patients had multidisciplinary team involvement with infectious diseases being the most consulted specialty. All pa-tients required in hospital IV antibiotic therapy and dressing changes. All were offered more than one out patient follow-up appointment. The total cost to our department surpassed AU$110 000 which represents four per cent of the total hospital spending on breast device explantations. Conclusion: Surgical complications from overseas implant procedures cost a small percentage of the hos-pital budget for breast procedures. However, with the increasing popularity of cosmetic tourism, this fig-ure could increase in the following years. We can use this information to educate individuals on making better choices while potentially reducing the financial burden to public hospitals in Queensland.

The changing face of cosmetic surgery regulation: a review of controversies and potential reforms

Cosmetic surgery is becoming increasingly popular in Australia with the industry estimated to be worth over 1 billion dollars annually. Regulators both in Australia and internationally have been criticized for not keeping up with the rapidly changing field and keeping patients sufficiently safe in an environment that is problematically entrepreneurial. In this article, we explore the current regulation of and controversies surrounding cosmetic surgery in Australia, including the use of the title 'cosmetic surgeon', consent processes and the phenomenon of medical tourism. Lastly, we review the potential future reforms in Australia and how other countries have regulated the industry to keep patients safe.

Medical Tourism in Aesthetic Breast Surgery: A Systematic Review

Introduction

Medical tourism is expanding on a global basis, with patients seeking cosmetic surgery in countries abroad. Little information is known regarding the risks and outcomes of cosmetic tourism, in particular, for aesthetic breast surgery. The majority of the literature involves retrospective case series with no defined comparator. We aimed to amalgamate the published data to date to ascertain the risks involved and the outcomes of cosmetic tourism for aesthetic breast surgery on a global basis.

Methods

A systematic review of PubMed, Google Scholar, EMBASE, the Cochrane library and OVID Medline was conducted using the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-analyses) guidelines. Keywords such as “medical tourism”, “cosmetic tourism”, “tourism”, “tourist”, “surgery”, “breast” and “outcomes” were used. Seven hundred and seventy-one titles were screened, and 86 abstracts were reviewed leaving 35 full texts. Twenty-four of these met the inclusion criteria and were used to extract data for this systematic review.

Results

One hundred and seventy-one patients partook in cosmetic tourism for aesthetic breast surgery. Forty-nine percent of patients had an implant-based procedure. Other procedures included: mastopexy (n=4), bilateral breast reduction (n=11) and silicone injections (n=2). Two-hundred and twenty-two complications were recorded, common complications included: wound infection in 39% (n=67), breast abscess/ collection in 12% (n=21), wound dehiscence in 12% (n= 20) and ruptured implant in 8% (n=13). Clavien–Dindo classification of the complications includes 88 (51%) IIIb complications with 103 returns to theatre, 2 class IV complications (ICU stay) and one class V death of a patient. Explantation occurred in 39% (n=32) of implant-based augmentation patients.

Conclusions

Aesthetic breast surgery tourism is popular within the cosmetic tourism industry. However, with infective complications (39%) and return to theatre rates (51%) significantly higher than expected, it is clear that having these procedures abroad significantly increases the risks involved. The high complication rate not only impacts individual patients, but also the home country healthcare systems. Professional bodies for cosmetic surgery in each country must highlight and educate patients how to lower this risk if they do choose to have cosmetic surgery abroad. In this current era of an intra-pandemic world where health care is already stretched, the burden from cosmetic tourism complications must be minimised.

Level of Evidence III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Infectious complications related to medical tourism

BACKGROUND

Medical tourism has been increasing dramatically globally, with people travelling from developed countries to low-income or middle-income countries, often to avoid high costs or long delays associated with seeking healthcare in their countries of origin. The current review summarizes healthcare-related infections associated with medical tourism, focusing on cosmetic surgery and organ transplantation.

METHODS

A systematic MEDLINE and PubMed search from January 2010 to December 2019 yielded 80 relevant articles, including 49 articles on medical tourism-related infections focusing on cosmetic surgery and organ transplantation, which were included in this reviews.

RESULTS

The literature reveals specific types of cross-border, healthcare-related infections depending on medical intervention. Destinations include low-income countries such as countries of Asia and the Indian subcontinent, middle-income countries including Central and South America, and high-income countries such as the United States and Europe. In terms of type of infections, in 36 (68%) and 15 (28.3%) studies, wound and blood-borne infections were documented, respectively, while in 21 studies (58.3%) non-tuberculous mycobacteria were isolated, including Mycobacterium abscessus, Mycobacterium chelonae, Mycobacterium senegalense and Mycobacterium fortuitum. The choices of medical tourists could have significant consequences for them and their home countries, including infectious complications and importation of pathogens, particularly antibiotic-resistant microorganisms, with public health implications.

CONCLUSIONS

There is a need for public health strategies in order to prevent morbidity and mortality as well as future management and education of patients engaging in medical tourism.

Plastic Surgery Complications: A Review for Emergency Clinicians

The number of aesthetic surgical procedures performed in the United States is increasing rapidly. Over 1.5 million surgical procedures and over three million nonsurgical procedures were performed in 2015 alone. Of these, the most common procedures included surgeries of the breast and abdominal wall, specifically implants, liposuction, and subcutaneous injections. Emergency clinicians may be tasked with the management of postoperative complications of cosmetic surgeries including postoperative infections, thromboembolic events, skin necrosis, hemorrhage, pulmonary edema, fat embolism syndrome, bowel cavity perforation, intra-abdominal injury, local seroma formation, and local anesthetic systemic toxicity. This review provides several guiding principles for management of acute complications. Understanding these complications and approach to their management is essential to optimizing patient care.

Complications Associated with Medical Tourism for Facial Rejuvenation: A Systematic Review

BACKGROUND

Medical tourism for cosmetic surgery has become increasingly popular in recent years. The existing literature has identified poor outcomes associated with general cosmetic tourism; however, the complications associated with cosmetic tourism for facial rejuvenation remain poorly understood. The aims of this study are to delineate the risk profile associated with medical tourism for facial rejuvenation.

METHODS

A systematic review of PubMed, MEDLINE, and Embase was performed through January 2019 using the PRISMA guidelines. Search terms included combinations of keywords including medical tourism and plastic surgery and other related nomenclature. Articles published in English relevant to medical tourism for facial rejuvenation and its associated complications were examined.

RESULTS

We identified six retrospective studies including 31 patients who had obtained facial rejuvenation procedures abroad and experienced treatment-associated complications. Twenty-five of 26 listed patients (96%) were female (age range 33-62 years). Departure nations included the USA, Switzerland, England, Ireland, Australia, and Thailand. Destination nations included the Dominican Republic, Cyprus, the USA, Colombia, Thailand, India, and China. Procedures included blepharoplasty, facelift, rhinoplasty, chin lift, and injections with botulinum toxin and dermal fillers. Complications included abscess, poor cosmesis, facial nerve palsy, and death.

CONCLUSIONS

We present the first study to systematically review the complications associated with medical tourism for facial rejuvenation. No definitive conclusions can be made given the paucity of relevant data, its clinical and statistical heterogeneity, and small sample size. Additional research is warranted to help inform patients who seek facial rejuvenation procedures abroad and to better understand the health system implications associated with cosmetic tourism for facial rejuvenation.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Cosmetic Tourism: a Costly Filler Within the National Health Service Budget or a Missed Financial Opportunity? A Local Cost Analysis and Examination of the Literature

BACKGROUND

Cosmetic tourism is a global commodity, but patients seeking treatment for complications of international cosmetic tourism appear to be on the rise. We calculate the financial burden to a single NHS trust and summarise the literature, reviewing the implications of cosmetic tourism and summarising available guidance to assist surgeons in this ethically challenging, but expanding, field.

METHODS

Hospital episodes for patients with complications from cosmetic tourism between January 2016 and March 2017 were retrieved using the patient management system. The coding department provided the episode costs. A literature search was conducted using Medline, EMBASE and HBE identifying 273 English abstracts. The abstracts were reviewed for relevance followed by assessment of the 48 selected full articles by all authors and 17 papers contained relevant, new information.

RESULTS

Eleven patients underwent management for complications of cosmetic surgery, most commonly infection, with a sum of 29 inpatient episodes and total cost of £259,732.

DISCUSSION

Our study illustrates the management of complications of cosmetic surgery carries a high cost. This is not an experience limited to just this trust in the UK. Internationally, healthcare systems are evolving to raise the safety profile for cosmetic tourists, some going the extra mile to accommodate healthcare tourists, reaping the financial reward. Following the examination of the literature, we query whether NHS trusts should heighten their presence as providers of private services on the international market, eliminating numerous medical-ethic concerns associated with substandard cosmetic tourism.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The Role of Outpatient Care Accreditation in Enhancing Foreign Patients' Perception of Colombian Medical Tourism: A Quasi-experimental Design

This study analyzes whether hospitals accredited by the Joint Commission International in outpatient medical care protocols located in Colombia achieve a higher quality perception from foreign patients compared to others treated in a non-accredited one. A t-test with Welch correction, chi-square test, correlation coefficient of Tau Kendall, pre-test, post-test, complementary questionnaire and a 2 focus groups were used in 178 foreign patients. It was observed that patients treated in accredited hospitals had a higher quality perception than the non-accredited group. However, it was found that an unbalanced application of the 3 variables negatively alters quality judgment. Findings contributes to understanding the Colombian medical tourism in depth using non-conventional instruments.

Patient care without borders: a systematic review of medical and surgical tourism

BACKGROUND

Medical tourism (MT) is an increasingly utilized modality for acquiring medical treatment for patients globally. This review assimilates the current literature regarding MT, with particular focus on the applications, ethics and economics.

METHODS

A systematic review of MEDLINE and PubMed Central databases for publications relating to MT from 2005 to 2018 yielded 43 articles for this review.

RESULTS

Patients seeking elective bariatric, cosmetic and orthopedic surgery abroad are motivated by significantly lower costs, all-inclusive vacation packages and reduced wait times. Complication rates as high as 56% include infection, poor aesthetic and functional outcome and adverse cardiovascular events. Cross-border reproductive care has steadily increased due to less restrictive policies in select countries; however, the depth of research on outcomes and quality of care is abysmal. Stem cell therapy promise treatments that are often not well researched and offer minimal evidence of efficacy, yet patients are drawn to treatment through anecdotal advertisements and a last sense of hope. Transplant surgery sought to decrease wait times carries many of the similar aforementioned risks and may contribute to the practice of organ trafficking in countries with high rates of poverty. Patients and countries alike are motivated by a plethora of factors to engage in the MT industry but may be doing so without accurate knowledge of the quality, safety or potential for economic gain. Safety is of utmost importance to prevent surgical complications and the spread of treatment-resistant bacteria.

CONCLUSIONS

MT is growing in popularity and complexity. The lack of standardization in its definition and regulation leads to difficulty in epidemiologic and economic analysis and ethical issues of informed consent and health equity. The findings of this review may be used by the stakeholders of MT, including patients and providers, to enhance informed decision-making and quality of care.

The "Game of Implants": A Perspective on the Crisis-Prone History of Breast Implants

Since their introduction into the market, breast implants have been the subject of many controversies. It is timely to examine the forces that have shaped the breast implant industry to make it what it is today. This review will concentrate more on the use of implants in aesthetic surgery rather than their use in breast reconstruction, but some of the factors have relevance to both indications.

Establishing Priorities for the International Confederation of Plastic Surgery Societies

Background

The mission of the International Confederation of Plastic Surgery Societies (ICOPLAST) is to improve patient outcomes through collaboratively structured processes in education, advocacy and communication. This article explains how we approached the task of establishing priorities for this nascent confederation in an equitable and achievable manner.

Methods

In late 2016, an online survey was sent to the inaugural 62 ICOPLAST member national societies for dissemination to their respective plastic surgeon members. Functional domains and proposed initiatives were ranked according to their level of importance by individual plastic surgeons.

Results

The survey was completed by 572 plastic surgeons. As a functional domain, education was highly ranked by 75.3% of respondents, followed by patient safety (67.4%), communication (59.3%), humanitarian (46.6%), regulation (41.2%), and advocacy (41.1%). Respondents also ranked individual initiatives within each domain to produce a compilation list of the top 13 initiatives of importance.

Conclusion

This study has identified priorities of importance to ICOPLAST members, which will aid in building a strategic framework and enhancing outcomes for patients, plastic surgeons, and the field of plastic surgery more broadly.