Literature Essay

Research

Aesthetic Surgery Journal 2017, Vol 37(4) 474–482 © 2016 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: [email protected] DOI: 10.1093/asj/sjw198 www.aestheticsurgeryjournal.com

Complications After Cosmetic Surgery Tourism

Holger J. Klein, MD; Dario Simic; Nina Fuchs, MD; Riccardo Schweizer, MD; Tarun Mehra, MD; Pietro Giovanoli, MD; and Jan A. Plock, MD

Abstract Background: Cosmetic surgery tourism characterizes a phenomenon of people traveling abroad for aesthetic surgery treatment. Problems arise when patients return with complications or need of follow-up care. Objectives: To investigate the complications of cosmetic surgery tourism treated at our hospital as well as to analyze arising costs for the health system. Methods: Between 2010 and 2014, we retrospectively included all patients presenting with complications arising from cosmetic surgery abroad. We reviewed medical records for patients’ characteristics including performed operations, complications, and treatment. Associated cost expenditure and Diagnose Related Groups (DRG)-related reimbursement were analyzed. Results: In total 109 patients were identified. All patients were female with a mean age of 38.5 ± 11.3 years. Most procedures were performed in South America (43%) and Southeast (29.4%) or central Europe (24.8%), respectively. Favored procedures were breast augmentation (39.4%), abdominoplasty (11%), and breast reduction (7.3%). Median time between the initial procedure abroad and presentation was 15 days (interquartile range [IQR], 9) for early, 81.5 days (IQR, 69.5) for midterm, and 4.9 years (IQR, 9.4) for late complications. Main complications were infections (25.7%), wound breakdown (19.3%), and pain/discomfort (14.7%). The majority of patients (63.3%) were treated conservatively; 34.8% became inpatients with a mean hospital stay of 5.2 ± 3.8 days. Overall DRG-related reimbursement premiums approximately covered the total costs. Conclusions: Despite warnings regarding associated risks, cosmetic surgery tourism has become increasingly popular. Efficient patients’ referral to secondary/tertiary care centers with standardized evaluation and treatment can limit arising costs without imposing a too large burden on the social healthcare system.

Level of Evidence: 4

Editorial Decision date: September 30, 2016; online publish-ahead-of-print November 14, 2016.

Medical tourism in general characterizes a phenomenon of people traveling abroad to access health treatment - reach- ing from dental procedures, assisted reproductive tech- nology, ophthalmologic and psychological care via cancer treatment, orthopedic and cardiac surgery, to organ and cellular transplantation and not least cosmetic surgery pro- cedures.1,2 While some countries in South America have developed strong reputations for aesthetic surgery and dental care, countries from Far East have become famous for general surgery procedures with medical services at particularly affordable prices being as low as 10% com- pared to those in the United States.3,4 Above that, even

industrialized countries such as Switzerland, Belgium, Germany, or Canada attract well-off patients from abroad offering sophisticated care with modern technologies focus- ing on patients’ preferences and satisfaction.1 It is not sur- prising, that this rapidly growing trend captures attention

From the University Hospital Zurich, Zurich, Switzerland.

Corresponding Author: Dr Jan A. Plock, University Hospital Zurich, Division of Plastic Surgery and Hand Surgery, Raemistrasse 100, 8091 Zurich, Switzerland. E-mail: [email protected]

Klein et al 475

in academic and popular media, which is underlined by a Google internet search for the term “medical tourism” result- ing in more than 30 million hits (performed in December 2015). Although precise records of people seeking medi- cal treatment abroad are lacking with an estimated high number of unknown cases, rough calculations account for about 6 million US Americans that claimed medical care overseas in 2010 - with the tendency to triple in 2017.5

Amongst the different types of medical tourism, cos- metic surgery procedures hold a special position and have proven to be particularly popular for different reasons. First, the phenomenon of cosmetic surgery tourism is largely price-driven as most of the requested procedures have to be paid out the patient’s own pocket - both in their home countries and abroad. Such cost-conscious patients mainly originating from highly industrialized countries are willing to accept certain inconveniences and insecurities in order to undergo aesthetic procedures at an attractively low price in less developed states.5-7 Travel agencies that specialize in whole package arrangements offering aes- thetic procedures performed by well-trained physicians in an often-luxurious ambience mollify the patient’s doubts and qualms. First world service at third world cost is the calculus in the scope of increasing healthcare expenditure in rich world countries.6 Cosmetic surgery tourism is addi- tionally fueled by the preservation of patients’ anonymity, shorter waiting lists, accessible online information, and the relative affordability of international airfares along with favorable economic exchange rates.8 Another factor con- tributing to this growing popularity of seeking procedures abroad is an increasing strive for consumerism where the patient can dictate requested surgical procedures.

Nonetheless, it remains to be questioned if travel agen- cies or private clinics abroad specializing in cosmetic sur- gery tourism can keep their glamorous promises. Whereas on-site complications might be directly handled by the surgeon/anesthesiologist in charge, problems arise when complications occur after the patient’s return in their home country. Even deaths of individuals traveling abroad for cosmetic and bariatric surgery have been reported in this context.9 In case of surgical failure or hospital negli- gence, it is often difficult for patients to receive adequate compensation for malpractice in many countries.10 As to that, initial savings might blur patients’ farsightedness.11 Consequently, sufficient follow up care is one of the most challenging hurdles that cosmetic surgery tourism is fac- ing today. Regularly reported complications are infec- tions, wound dehiscence, pain/discomfort and aesthetic dissatisfaction.5,6,12,13

Although cosmetic surgery tourism as a niche has become a stand-alone industry, little is known about clin- ical outcomes, complication rates, opportunity costs, and responsibility regarding treatment of complications and cost coverage. Any direct numbers regarding quality-control

or patient satisfaction are lacking for self-explanatory reasons. However, as the trend for cosmetic procedures abroad continues to grow, so does the need for an effi- cient management of resulting complications. Increasing numbers of individuals have presented to our department requesting treatment during the last 5 years. In this retro- spective study, we set out to investigate these complica- tions of cosmetic surgery tourism as well as to analyze cost effectiveness of treatment for complications at our center.

METHODS

Approval was obtained from the Ethics Committee of the University of Zurich (KEK-ZH-Nr. 2014-0585). We retro- spectively included all patients presenting as emergency cases or as outpatients at our department between 2010 and 2014 with complications arising from cosmetic sur- gery abroad. Concerned medical records were reviewed for patients’ characteristics including performed oper- ations, follow-up period, geographical area and surgical complications. Chart review was conducted in July 2015. Performed procedures abroad were grouped according to their type of surgery: breast surgery (augmentation, reduction, mastopexy, change of implants), body con- touring (abdominoplasty, liposuction, thigh lift, brachio- plasty), facial surgery (facelift, otoplasty, blepharoplasty, rhinoplasty), injections (botulinum toxin, fillers), and others (eg, hair transplantation, genital rejuvenation sur- gery). Follow-up period between the initial procedure abroad and presentation at our department was subdivid- ed into early (≤30 days), midterm (30-180 days) and late (>180 days) occurrence of complications.

Costs were defined as total direct costs of inpatient care, allocated to each case under the REKOLE (Bern, Switzerland) full cost accounting method.14 REKOLE is the Swiss national cost accounting system for hospitals. National legislation demanded comparability and trans- parency in hospital cost accounting, which is why REKOLE was introduced. It is a full cost accounting method with the hospital case being the cost unit, which means that all costs including overheads are allocated to the treated patients. Revenue was defined as the total earnings per case, taking into account the change of the reimbursement system from a largely per-diem based system to a Diagnose Related Groups (DRG)-based prospective payment system for discharges after January 2012. The case earnings were calculated by subtracting the case costs from the calcu- lated case revenue. The accuracy of revenue-determining coding as well as cost data in Switzerland is continuously subject to external and independent audits.

Data were analysed using Statistical Package for Social Sciences (SPSS, Version 20 for Macintosh; Chicago, IL). Discrete values are expressed as counts (percentages) and continuous variables as means (standard deviation [SD])

476 Aesthetic Surgery Journal 37(4)

or medians (interquartile range [IQR]) according to their distribution.

RESULTS

A total of 109 patients presenting with complications sec- ondary to cosmetic procedures abroad were identified in the period between 2010 and 2014 (Figure 1). All patients were female with a mean age of 35.1 years (SD, 10.5) (range, 18- 62 years) at procedure abroad, while mean age at presenta- tion was 38.2 years (SD, 11.3) (range, 20-73 years). Over- all median follow-up time between the initial procedure abroad and presentation at our department was 84 days (IQR, 616 days). Forty patients presented with early compli- cations (≤30 days) with a median follow-up time of 15 days (IQR, 9 days) (Table 1). Ten of these “early complication” patients (25%) needed immediate revision surgery due to acute infection, implant exposure, wound breakdown, or hematoma. The remaining 30 patients (75%) were treat- ed conservatively with antibiotics and/or regular wound care; eventually 4 of these patients (10%) had to under- go revision surgery subsequently as conservative treatment failed. Twenty-eight patients suffering from midterm com- plications (31-180 days) presented after 81.5 days (IQR, 69.5 days) (Table 1). This “midterm complication” group comprised 28 patients (26%) with 10 patients presenting with wound breakdown, 7 patients with pain/discomfort, 5 patients with delayed infection, and 2 patients who com- plained about the aesthetic result. The rate for immediate reoperation was as low as 7% (2 patients) in this group. Conservative treatment was predominant (71%), 6 patients had to be operated subsequently when conservative man-

agement failed. Late complications (>180 days) were found in 41 patients with a median follow-up period of 2.96 years (IQR, 9.4 days) (Table 1). This “late complication” group with 41 patients (38%) included unsatisfying results in 5 patients, prolonged pain/discomfort in 8, implant rupture in 8, capsular contracture in 7, and infection mostly due to late seroma in another 4 patients. None of these patients had to be operated immediately. Elective surgical intervention was required in 18 patients.

Breast surgery was the most frequent procedure with 68 cases (62.4%), while 17 patients (15.6%) underwent body contouring procedures; facial surgery was performed in 5 patients (4.6%), while 14 patients (12.8%) underwent injections with botulinum toxin or fillers (Table 1, Figure 2). Main complications were infections (25.7%) followed by wound breakdown (19.3%), pain/discomfort (14.7%), implant rupture (8.3%), capsular contracture (6.4%), dis- satisfaction with the aesthetic result (6.4%), and hematoma (5.5%) (Table 1, Figure 3). Most procedures were performed in South America (30.3%) and Southeast (29.4%) or Middle Europe (24.8%), respectively (Tables 2-4).

The majority of patients presented via our emergency department (n = 68, 62.4%), none of them in instable condition. All other patients referred themselves to our outpatient clinic (n = 41, 47.6%). Thirty-eight patients (34.8%) became inpatients with a mean hospital stay of 5.2 days (SD, 3.9 days). None of them required medical intensive care. Almost two-third of these patients (n = 69, 63.3%) were treated conservatively with administration of antibiotics (n = 17). Forty patients (36.7%) needed revision surgery, most of them due to infection (n = 19). Table 5 shows the numbers of patients according to the type of consultation (outpatient vs inpatient) and the type of treatment (conservative vs surgery).

Total cost expenditure reached SFr 530,000 (~US $534,000, ~EUR 486,000) while (DRG-related) reimburse- ment was SFr 550,000 (~US $554,000, ~EUR 505,000), resulting in a slight overall financial gain of SFr 20,000 (~US $20,000, ~EUR 19,000) for the population of 109 patients. Inpatients caused significantly higher costs (SFr 10,000, US $10,100, EUR 9200 per patient) than outpatients (SFr 3800, US $3830, EUR 3490 per patient). Inpatients were profitable with mean gains of SFr 1287 (~US $1300, ~EUR 1180) per patient, while outpatients (including partial inpa- tients) caused an average loss of SFr −415 (US $418, EUR 381) per patient in our tertiary hospital setting (exchange rate per July 26, 2016: 1 SFr = 0.92 EUR = 1.01 USD).

DISCUSSION

According to an ISAPS-based (International Society of Aesthetic Plastic Surgery) article from 2011, highest per- centages of cosmetic procedures worldwide are performed

Figure 1. Number of patients with complications related to cosmetic surgery tourism per year.

Klein et al 477

in Switzerland with 59 operations per 10,000 citizens. For comparison, highest total numbers of cosmetic procedures are reported for the United States, however accounting for only 35 cosmetic procedures per 10,000 citizens.15 Independently of these striking numbers, skyrocketing healthcare costs make people of industrialized countries gradually claim medical treatment abroad. Consequently, the willingness to undergo surgery abroad has gained an entirely new dimension making cosmetic surgery tourism a thriving industry. As complications are unavoidable, healthcare systems of patients’ home countries have to face the consequences in return. Although absolute num- bers of people traveling abroad for cosmetic surgery are lacking, we were able to observe this rapidly growing trend

for Switzerland, too (Figure 1): An increasing number of patients presented to our department with complications secondary to cosmetic surgery abroad between 2010 and 2014. Allowing for the fact that quality and safety of these procedures might have ameliorated during the last decade, the almost exponentially rising number of complications gives a rough idea of the extent of this phenomenon. This increase might even be underestimated as cosmetic sur- gery tourism is absolutely trending in Europe and even more so in Switzerland with the high price level. There is no official data available. Financial reasons are current- ly driving this trend and being a tertiary public hospital we are supposed to help for any medical issue within the Swiss healthcare system. The Division of Plastic Surgery

Figure 2. Percentage of performed procedures abroad. Figure 3. Percentage of complications related to cosmetic surgery tourism.

Table 1. Procedures Performed and Complications According to their Temporal Occurrence

Early (≤30 days) Midterm (31-180 days) Late (>180 days) Total

Procedure

Breast surgery 25 19 24 68 (62.4%)

Body contouring 9 5 3 17 (15.6%)

Injections 2 2 10 14 (12.8%)

Facial surgery 3 1 1 5 (4.6%)

Others 1 1 3 5 (4.6%)

Complication

Infection 19 5 4 28 (25.7%)

Wound breakdown 8 10 3 21 (19.3%)

Pain/discomfort 1 7 8 16 (14.7%)

Implant rupture 1 8 9 (8.3%)

Dissatisfaction 2 5 7 (6.4%)

Capsular contracture 7 7 (6.4%)

Hematoma 5 1 6 (5.5%)

Others 6 3 6 15 (13.8%)

478 Aesthetic Surgery Journal 37(4)

and Hand Surgery at the University Hospital Zurich pro- vides up to 30 beds for inpatients and serves the popula- tion of Zurich with about 380,000 citizens and its cantonal area with a total population of 1.4 million citizens. How- ever, further hospitals of Zurich and its adjacent area con- tribute to patients’ healthcare. The annual report of 2015 revealed nearly 6000 consultations and 1650 procedures for plastic surgery reasons (including aesthetic surgery) at our division.16 Numbers on purely aesthetic operations make up for approximately 10%.

We found breast surgery (62%) along with body con- touring (15%) and injections (13%) as the most frequently performed procedures, which is in line with previous studies conducted in Europe.6,12,13,17 Miyagi et al investi- gated the same issue for the United Kingdom (UK) pre- senting complications secondary to breast surgery in 74% and body contouring in 21%.6 Of note, the mean age in Miyagi et al’s study (43.5 years; range, 30-60 years; survey period, 2007-2009) was remarkably higher in contrast to our finding (35.1 years; range, 18-62 years; survey period, 2010-2014). This might largely be related to the growing desire of younger patients for cosmetic surgery. We found wound infection (26%) as predominant complication after cosmetic surgery abroad, followed by wound breakdown (19%) and pain/discomfort (15%). This basically con- firms the results of earlier studies, which were conducted in Great Britain and the United States.5,6,13 Interestingly, a recent study from the United States presented a series of patients with mycobacterial infections after cosmetic surgery in developing countries.18 The authors stated that the endemic nature of these bacteria combined with a low

domestic (in the United States) incidence of related infec- tions might delay diagnosis and adequate treatment. In our study, two of our 28 infectious complications were related to mycobacteria and correct microbiological results were delayed by approximately four weeks in both cases. Thus consulting physicians should have a low threshold to con- sider atypical etiologies in such scenarios.

Notwithstanding, Miyagi et al as well as Jeevan et al reported complications due to poor cosmetic results in 37% and 26% respectively, which remarkably differs from our finding (6%).6,17 A possible reason for this difference might be the fact that Miyagi et al conducted their study in a tertiary referral Plastic Surgery practice and Jeevan et al received their data from a questionnaire, which was answered by 203 UK consultant plastic surgeons mainly belonging to the private sector. There may be a significant bias of complicated cases presenting in public hospitals with emergency units and plastic surgery private practices - the latter ones probably seeing more late complications and aesthetic dissatisfaction. Of note, pertinent literature does not provide data on complications resulting from local injections such as botulinum toxin or fillers. However, this type of complication was observed in 13% of our patients reflecting the growing sector of “minimal invasive rejuve- nation.” These quite affordable and quick procedures are meanwhile regularly offered as “to-go” interventions along the road or at exclusive hotels.

Overall median follow-up time between the initial pro- cedure abroad and presentation at our department was 84 days (IQR 616 days). The large IQR of the overall fol- low up period was related to patients presenting several

Table 2. Procedures Performed According to their Originating Subcontinent

Breast surgery Body contouring Facial surgery Injections Others Total

America

South America 21 4 0 6 2 33 (30.3%)

North America 1 0 0 0 0 1 (0.9%)

Europe

Middle Europe 21 3 2 1 0 27 (24.8%)

South Europe 3 0 0 0 0 3 (2.8%)

West Europe 1 0 0 1 1 3 (2.8%)

Asia

Far East 2 0 0 1 1 4 (3.7%)

Middle East 0 1 0 1 0 2 (1.8%)

Africa

North Africa 2 1 0 1 0 4 (3.7%)

Total 68 (62.4%) 17 (15.6%) 5 (4.6%) 14 (12.8%) 5 (4.6%)

Klein et al 479

months/years after the initial operation abroad (eg, in case of capsular contracture). These “outliers” diminish the meaningfulness of the overall median follow-up period in terms of a significant skewedness. Accordingly, we subdi- vided our cohort into three groups corresponding to their time-dependent occurrence of complications (early/acute, midterm, late complications) with more informative and statistically more reliable follow up medians. Early com- plications occurring within the first 30 days after opera- tion include acute, possibly life-threatening complications such as infections, hematoma/bleeding or dehiscence potentially necessitating urgent surgical revision. With the end of this “early” period, regular wound healing should allegedly be completed and severe consequences become rather unlikely. The “midterm” group comprises compli- cations that are directly related to the operation abroad, but do mostly not require urgent intervention. During this period scar formation is peaking and possibly leading to pain/discomfort, and delayed wound-healing disorders are to be expected. Additionally, patients usually start judging the cosmetic result after wound healing has terminated and swellings have vanished accounting for complaints due to poor aesthetic result. Patients also start doing sports and participate more in social activities, which may influence judgments and discomfort during this period. Eventually, the “late group” includes unsatisfying results, chronic prob- lems like prolonged pain/discomfort, implant rupture, or capsular contracture. None of the “late group” patients had to be operated immediately. If conservative treatment fails or is impossible (eg, capsular contracture), elec- tive surgery may be an option. Each group of the present study accounted for more or less one-third of the patients. Notwithstanding this fact, almost two-third of the patients presented via our emergency room, notably none of them in unstable condition. Initial consultation in the emergency room is associated with higher costs for the national health- care system and prolonged waiting time for the patients. Additionally, pressure on already overstretched emergency units should be avoided. Consequently, the provided cat- egorization might help primary and secondary care ser- vices to refer patients either directly to the emergency room (early category) or re-schedule for an appointment in the outpatient clinic (midterm, late category). As to that, Supplementary Figure 1 provides a complementary outline aiming at cost and resource effective triage and treatment limitations of patients with complications secondary to cosmetic surgery abroad. Note, that boundaries between the categories might partly be fluent. Under these circum- stances taking care of “early” complication cases after sur- gery abroad may financially be more attractive for public hospitals and teaching units than in the private setting of aesthetic plastic surgeons. Emergency availability, immedi- ate diagnostic tools, bed and operating room capacity, as well as personnel resources may advocate for treatment of

Table 3. Country-Related Numbers of Performed Operations

America

South America 33 (30.3%)

Brazil 16

Colombia 5

Dominican Republic 4

Venezuela 4

Ecuador 3

Peru 1

United States 1 (0.9%)

Europe

Southeast Europe 32 (29.4%)

Turkey 14

Serbia 8

Bulgaria 2

Croatia 2

Macedonia 2

Romania 2

Slovenia 2

Middle Europe 27 (24.8%)

Germany 10

Czech Republic 9

Austria 3

Poland 3

Belgium 1

Hungary 1

South Europe 3 (2.8%)

Italy 2

Portugal 1

West Europe 3 (2.8%)

United Kingdom 2

France 1

Asia

Far East 4 (3.7%)

Thailand 3

India 1

Middle East 2 (1.8%)

Emirates 1

Lebanon 1

Africa

North Africa 4 (3.7%)

Morocco 2

Tunisia 2

480 Aesthetic Surgery Journal 37(4)

acute complications in secondary and tertiary care centers, while the mid- and long-term complications may be served equally well in the private sector or in specialized hospital outpatient clinics predominantly on patients own cost.

Of note, all patients of our study were female, which significantly differs from data provided by the American Society for Aesthetic Plastic Surgery with 10.3% of sur- gical and 9.4% of nonsurgical procedures are performed on males.19 This might be related to the fact that aesthetic

surgery in males in Europe is not as common as in the United States. To the best of our knowledge there is no data available on gender related cosmetic surgery tourism.

Healthcare in Switzerland is universal and is reg- ulated by the Swiss Federal Law on Health Insurance. There are no free state-provided health services, but health insurance is compulsory for all persons resid- ing in Switzerland. Health insurance covers the costs of medical treatment and hospitalization of the insured.

Table 4. Subcontinent-Related Numbers of Complications

Infection Hematoma Wound breakdown

Pain/discomfort Implant rupture Dissatisfaction Capsular contracture

Others Total

South America 9 1 7 2 4 1 2 7 33

South East Europe

6 3 8 4 1 4 0 6 32

Middle Europe 8 1 4 7 3 2 2 0 27

Far East 1 0 0 0 0 0 2 1 4

North Africa 2 0 1 1 0 0 0 0 4

South Europe 0 1 1 0 1 0 0 0 3

West Europe 1 0 0 1 0 0 1 0 3

Middle East 1 0 0 0 0 0 0 1 2

North America 0 0 0 1 0 0 0 0 1

Table 5. Number of Patients According to the Type of Consultation (Outpatient vs Inpatient) and the Type of Treatment (Conservative vs Surgery)

Type of consultation Type of treatment

Outpatient (65%) Inpatient (35%) Conservative (63%) Operation (37%)

Procedure

Breast surgery 44 (64.7%) 24 (35.3%) 44 (64.7%) 24 (35.3%)

Body contouring 12 (70.6%) 5 (29.4%) 11 (64.7%) 6 (35.3%)

Injections 7 (50%) 7 (50%) 7 (50%) 7 (50%)

Facial surgery 5 (100%) - 4 (80%) 1 (20%)

Others 3 (60%) 2 (40%) 3 (60%) 2 (40%)

Complication

Infection 7 (25%) 21 (75%) 9 (32.1%) 19 (77.9%)

Wound breakdown 19 (90.5%) 2 (9.8%) 19 (90.5%) 2 (9.53%)

Pain/discomfort 15 (93.8%) 1 (6.2%) 14 (87.5%) 2 (12.5%)

Implant rupture 4 (44.4%) 5 (56.6%) 4 (44.4%) 5 (55.6%)

Dissatisfaction 7 (100%) - 6 (85.7%) 1 (14.3%)

Capsular contracture 3 (42.9%) 4 (57.1%) 3 (42.9%) 4 (57.1%)

Hematoma 5 (83.3%) 1 (16.7%) 5 (83.3%) 1 (16.7%)

Others 11 (73.3%) 4 (26.7%) 9 (60.0%) 6 (40%)

Klein et al 481

However, the insured person pays part of the treatment costs by means of an annual deductible (called “fran- chise”, ranging US $184-1534) and by a charge of 10% of the costs. As to that, the Swiss national healthcare sys- tem takes care for complications resulting from surgical interventions regardless of whether the primary surgery was performed domestically or abroad. Excluded from this lawful obligation are purely aesthetic complaints. Though, even in these cases, an insurance inquiry can be made on an individual basis.

Switzerland has a propitious geographic location in the center of Europe enabling people to seek aesthetic surgery abroad within few hours - guaranteeing remarkably lower prices, shorter waiting lists, excellent care, and quality in a luxurious ambience and the possibility to combine holidays with cosmetic procedures. Our data reflect this assumption as almost 60% of the patients underwent beauty surgery in neighboring European countries. Within Europe, favored countries are Turkey, Germany, Czech Republic, and Serbia - probably offering the best combination of low prices, well- trained physicians, high standard care, informative and trustworthy internet presence, and none/reduced language barriers. Three earlier studies, conducted in the UK, con- sistently found the neighboring European countries (espe- cially the Southeast of Europe) as primary destination for cosmetic surgery tourists.5,6,17 Outside Europe, despite long travel distances, South America (30%) has proven its popularity for cosmetic surgery tourism with Brazil (15%) as market leader. Attractive airfares and a not irrelevant percentage of South American (45,000, 0.5%), Spanish (85,000, 1%), and Portuguese (275,000, 3%) immigrants might explain this trend20 for Switzerland.

In the age of DRG revenue management, analysis of cost effectiveness plays an increasingly important role. Our results indicate that the treatment of complications resulting from cosmetic surgery tourism can be handled cost-effectively. Considerable potential for savings lies in the referral of non-emergency cases to the outpatient clinic instead of the emergency room. Adequate comparable data are lacking in pertinent literature; merely Miyagi et al reported that remuneration provided by the Primary Care Trust (UK) to the hospital was less than 70% of the actual expenditure. To be mentioned, international comparisons of costs and reimbursement need to be adjusted to the rel- atively high cost and reimbursement level for medical care in Switzerland.21

Several international collaborative initiatives have faced the problems of cosmetic surgery tourism by establish- ing recognized contracts including measures for ensur- ing accountability if complications arise, appropriate hygiene standards and post-procedural care. In addition, the International Society of Aesthetic and Plastic Surgery (ISAPS) and the American Society of Aesthetic and Plastic Surgeons (ASAPS) have issued guidance for patients on

the risks of cosmetic tourism and information they should seek prior to any procedure abroad.22 The latter includes the ISAPS Patient Safety Diamond, which emphasizes four facets that the patient should establish. These include details of the operation (including indications, likelihood of success, and associated risks), qualifications and track record of the surgeon, quality and resources of the health- care facility, and the appropriateness for the individual patient to undergo the specified procedure.

Although this is the first survey addressing cosmetic surgery complications in Switzerland, our study is limited by the fact that a national database on absolute numbers of Swiss people seeking cosmetic procedures abroad is lack- ing. Consequently, relative numbers serving as “quality feature” for cosmetic procedures abroad cannot be calcu- lated. Likewise, numbers from neighboring hospitals treat- ing complications secondary to cosmetic surgery tourism have not been included in our study for ethical reasons (inter-cantonal ethical approval and individual informed consent from all patients is required). Moreover, patient numbers seeking cosmetic procedures abroad might be lower for other countries so that the results presented here may not be directly transferred to other health systems and societies. As the price level in Switzerland is relatively high in comparison to adjacent countries in Europe and the size of the country is limited, patients are motivated to seek cosmetic procedures at lower cost within reasonable travel time. Future studies should also include data on patients’ ethnicity and descent.

CONCLUSIONS

Cosmetic surgery tourism has become a stand-alone in- dustry with ongoing trend to expand. Overall complica- tion rates as markers for the quality of surgery performed abroad remain unknown, as data on the total number of these procedures is lacking. Following efficient patients’ referral with subsequent professional evaluation and treat- ment in qualified plastic surgery units, immediate as well as later occurring complications secondary to cosmetic surgery abroad can be treated effectively at reasonable costs without imposing a too high burden on the social healthcare system. The majority of complications can be treated conservatively and in an ambulatory setting.

Supplementary Material

This article contains supplementary material located on- line at www.aestheticsurgeryjournal.com.

Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

482 Aesthetic Surgery Journal 37(4)

Funding The authors received no financial support for the research, authorship, and publication of this article.

REFERENCES

1. Horowitz MD, Rosensweig JA, Jones CA. Medical tourism: globalization of the healthcare marketplace. MedGenMed. 2007;9(4):33.

2. Lunt N, Organisation for Economic Co-Operation and Development, Directorate for Employment L, Social A. Medical tourism treatments, markets and health system implications: a scoping review. 2011; http://www.oecd. org/dataoecd/51/11/48723982.pdf. Accessed January 22, 2016.

3. Schult J. Beauty from Afar: A Medical Tourist’s Guide to Affordable and Quality Cosmetic Care Outside the U.S. New York; London: Stewart, Tabori & Chang; Thames & Hudson [distributor]; 2006.

4. Hancock D. The complete medical tourist your guide to inexpensive dental cosmetic and medical surgery abroad. 2006; http://public.eblib.com/choice/publicfullrecord.as- px?p=861133. Accessed April 04, 2016.

5. Melendez MM, Alizadeh K. Complications from interna- tional surgery tourism. Aesthet Surg J. 2011;31(6):694- 697.

6. Miyagi K, Auberson D, Patel AJ, Malata CM. The unwrit- ten price of cosmetic tourism: an observational study and cost analysis. J Plast Reconstr Aesthet Surg. 2012;65(1):22- 28.

7. Penney K, Snyder J, Crooks VA, Johnston R. Risk com- munication and informed consent in the medical tourism industry: a thematic content analysis of Canadian broker websites. BMC Med Ethics. 2011;12:17.

8. Connell J. Medical tourism: sea, sun, sand and surgery. Tourism Manag. 2006;27(6):1093-1100.

9. Turner L. News media reports of patient deaths following ‘medical tourism’ for cosmetic surgery and bariatric sur- gery. Dev World Bioeth. 2012;12(1):21-34.

10. Terry NP. Under-regulated health care phenomena in a flat world: medical tourism and outsourcing. West New Engl Law Rev. 2007;29(2):421-472.

11. Nassab R, Hamnett N, Nelson K, et al. Cosmetic tourism: public opinion and analysis of information and content available on the Internet. Aesthet Surg J. 2010;30(3):465- 469.

12. Jeevan R, Armstrong A. Cosmetic tourism and the burden on the NHS. J Plast Reconstr Aesthet Surg. 2008;61(12):1423-1424.

13. Birch J, Caulfield R, Ramakrishnan V. The complications of ‘cosmetic tourism’—an avoidable burden on the NHS. J Plast Reconstr Aesthet Surg. 2007;60(9):1075-1077.

14. REKOLE Handbuch—Betriebliches Rechnungswesen im Spital. 4th ed. Bern, Switzerland; 2016.

15. Tagesanzeiger. http://blog.tagesanzeiger.ch/datenblog/ index.php/253/schoehnheitsoperationen-boomen. 2014. Accessed August 22, 2016.

16. Universitätsspital_Zürich. Jahresbericht 2015, http:// www.usz.ch/ueber-uns/Documents/geschaeftsberi- cht_2015.pdf. 2015. Accessed July 14, 2016.

17. Jeevan R, Birch J, Armstrong AP. Travelling abroad for aesthetic surgery: Informing healthcare practitioners and providers while improving patient safety. J Plast Reconstr Aesthet Surg. 2011;64(2):143-147.

18. Singh M, Dugdale CM, Solomon IH et al. Rapid-growing my- cobacteria infections in medical tourists: our experience and literature review. Aesthet Surg J. 2016;36(8):NP246-NP253.

19. The American Society for Aesthetic Plastic Surgery. http://www.surgery.org/media/statistics. Accessed Au- gust 01, 2016.

20. Staatssekretariat für Migration SEM. Ausländerstatistik November 2015. https://http://www.sem.admin.ch/ sem/de/home/publiservice/statistik/auslaenderstatistik/ archiv/2015/11.html. Accessed January 09, 2016.

21. Bundesamt für Statistik, Sektion G. Gesundheitsstatistik 2014. Neuchatel: Office fédéral de la statistique (OFS).

22. Nahai F. Minimizing risk in aesthetic surgery. Clinical Risk. 2009;15(6):232-236.

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