Safety Issues in Office-Based Plastic Surgery

The overwhelming acceptance of plastic surgery by the general public is evident in the recent dramatic growth in both the frequency and diversity of procedures performed on an annual basis. Cosmetic surgery has seen the most dramatic growth. In the United States alone, there are now more than two million aesthetic surgical procedures performed annually. In addition, there are over 13 million minimally-invasive procedures performed in the U.S. A significantly increasing percentage of procedures are now performed on an outpatient basis. Statistics from the American Academy of Facial Plastic and Reconstructive Surgery and the American Society of Plastic Surgeons indicate that well over 50 percent of cosmetic plastic surgical procedures are now performed in an office-based facility. While the initial growth of office-based surgery took place in a largely unregulated environment, a number of unfortunate complications in Florida and California led to the recognition of the need for appropriate standards of care in the late 1990s.

In 2001, a special committee of the Federation of State Medical Boards (FSMB) on outpatient office-based surgery began to develop core principles for appropriate regulation of this industry. They were joined by the American Medical Association and the American College of Surgeons, The American Academy of Facial Plastic and Reconstructive Surgery and the American Society of Plastic Surgeons, among others. At the same time, some states began to follow New Jersey, California and Florida, who, by the year 2000, had already established their own regulations for office-based surgery. While that number now stands at a total of 14 states, Illinois is not included.

Other than individual state regulations, the oversight of office-based surgery is currently being addressed by the Federation of State Medical Board model guidelines or national accrediting organization standards. These standards take into consideration the level of anesthesia defined by the American Society of Anesthesiologists.

There are currently three accrediting organizations involved with the process of office-based surgical facilities. The Accreditation Association for Ambulatory Health Care (AAAHC) is the largest national accreditor of ambulatory health care, accrediting 2,530 organizations, including 1800 surgery centers. In addition, the American Association for Accreditation for Ambulatory Surgery (AAAS) and the Joint Committee on Accreditation of Hospital Outpatient Facilities (JCAHOF) are actively involved in this process. To achieve accreditation by one of these organizations requires substantial compliance with standards applicable to all hospitals and licensed accredited outpatient surgery centers. This requires a considerable investment of time, money, intellect and energy. The actual survey process, although completed in one day by a single surveyor, is exhaustive. Successfully accredited facilities are awarded up to a three-year cycle for re-accreditation.

One of the major goals of this process is to confirm the quality of patient care provided, including the appropriate safety standards for surgery and anesthesia. Currently, AAAHC accreditation requires a total of 21 core standards which must be met. These can be reviewed by logging onto the AAAHC website, www.aaahc.org.

To help ensure patient safety in office-based facilities in which conscious sedation or general anesthesia are utilized, both the American Academy of Facial Plastic and Reconstructive Surgery and the American Society of Plastic Surgeons require all board-certified surgeons to perform outpatient plastic surgery in an accredited facility. This is especially important when deeper levels of anesthesia are involved. Unfortunately, there are still other plastic surgical societies or organizations which have not adopted this requirement. Thus, the safety standards in a state such as Illinois can vary considerably from one office to another. The recent unfortunate death of a five-year-old in a pediatric dental office in Chicago has once again brought attention to the safety of office outpatient surgery in which deep anesthesia is administered. It also led to outcries for stricter regulations and standards in Illinois. The issue is being revisited by the Illinois Department of Public Health and the Illinois Department of Professional Regulation at this time.

Ironically, recent surveys on outpatient office surgery in accredited facilities by the American Academy of Facial Plastic Surgery and the American Society of Plastic Surgeons have confirmed a remarkable improvement in safety and lack of complications in recent years, coincident with the adoption of accreditation standards and other safety measures by both organizations.

While some argue that regulations and accreditation will not always guarantee safe and high-quality patient care, a good starting point is required. Organizations with a deliberate and focused approach to accreditation will be in the best position to offer higher levels of consistent quality to the patients they serve. Patients contemplating elective cosmetic plastic surgery in an office outpatient facility deserve to see verifiable evidence of compliance with safety measures and quality of care and documented accreditation of their surgeons’ facilities. TPW