Plastic Surgery Volume 1 Principles 4th

59
Legal and regulatory considerations
used to fund projects and programs in energy, communica­
tions, education, and transportation, healthcare received $151
billion, with the vast majority of this money used to support
Medicare. In the wake of this stimulus package, the national
economy has remained volatile but appears to have stabilized,
and the demand for healthcare services has not decreased, as
many economists predicted.
Patient Protection and Affordable Care
Act, 2010
In a bitterly fought, highly publicized partisan struggle,64
Congress eventually passed the Patient Protection and Afford­
able Care Act (ACA), which is essentially a healthcare reform
bill that focuses on health insurance reform.41 Described as the
most significant overhaul of the US healthcare system since
Medicare and Medicaid in 1965, the ACA was enacted to
increase the quality and affordability of health insurance,
lower the uninsured rate by expanding public and private
insurance coverage, and reduce the costs of healthcare for
individuals and the government. Benefits of this legislation
include expanded Medicaid eligibility, subsidized insurance
premiums, incentives for small businesses to provide health­
care coverage, prohibition of denials by insurance companies,
establishing a market of health insurance “exchanges”, and
financial support of medical research and information tech­
nology, such as the electronic medical record.
Critics insist that the proposed deficit reduction of $143
billion, over the first decade, will be neither achievable nor
maintainable. The cost of this plan is offset by fees on phar­
maceutical companies and on medical devices, new taxes
on high-income brackets, improved efficiencies from informa­
tion technology, and reduced administrative expenses. The
Supreme Court has upheld the constitutionality of the ACA
on two occasions, affirming the legality of the individual
mandate and the federal subsidy, but ruled that individual
states cannot be forced to participate in Medicaid expansion.
However, over a third of the 32 million uninsured adults from
2011 now have health insurance, dropping the uninsured rate
from 18.4% to 11.4%, by mid-2015.
Dodd–Frank Wall Street Reform and
Consumer Protection Act, 2010
Already considered the most sweeping change to financial
reform since the Great Depression, the Dodd–Frank Wall
Street Reform and Consumer Protection Act is designed to
permanently fix the economic problems that the Stimulus Act
helped to stabilize.42 The aim of the bill is as follows: “To
promote the financial stability of the United States by improv­
ing accountability and transparency in the financial system,
to end “too big to fail”, to protect the American taxpayer by
ending bailouts, (and) to protect consumers from abusive
financial services practices.” The impact on the financial regu­
latory system will certainly be far-reaching, with significant
restructuring of the flow of capital within our economy. Spe­
cific targets of reform include hedge funds and other invest­
ment banking instruments, the Federal Reserve, Wall Street
transparency and accountability, mortgage and commercial
lending institutions, and consumer and investor protection
programs. The question for the healthcare industry is not if
the Dodd–Frank Act will affect healthcare delivery, but how.
entity owned by one person, who assumes personal liability
for debts incurred by the business. A partnership is a type of
business in which two or more individuals agree to share
profits but also liabilities; the advantage of such a structure,
like that of a proprietorship, is that net income is taxed only
once. A corporation is a business with a distinct and separate
identity from its members; for-profit and not-for-profit corpo­
rations must be owned by multiple shareholders and are
overseen by a board of directors, which manages the execu­
tive team. Most hospitals follow this model, while many
physicians in private practice may function as a proprietor or
as the head of an S-corporation. Finally, a cooperative is a type
of corporation with limited liability whose members, in con­
trast to shareholders, share decision-making capabilities. One
disadvantage of corporations and cooperatives is that profit
is subject to double taxation: first on net income of the entity,
after operating and indirect expenses are deducted, and
second on the returns to the stakeholders, in the form of
personal income, dividends, and other capital gains such as
stock that is sold.
Sarbanes–Oxley Act, 2002
In response to such corporate and accounting scandals as
Enron, Tyco, and WorldCom, as well as the “dotcom” bubble
that burst and cost investors billions of dollars, both the
House and the Senate overwhelmingly supported and passed
the Sarbanes–Oxley Act (SOX).39 Public confidence in the
nation’s securities markets had been greatly undermined, and
this legislation attempted to restore the stability of these
markets, through oversight and control. In addition to creat­
ing a Public Company Accounting Oversight Board, SOX
mandated that: 1) auditors could not provide consulting ser­
vices to the same clients; 2) senior executives must take
individual responsibility for the accuracy and completeness
of their corporate financial reports; and 3) financial disclosures
of public companies must include enhanced reporting of off-
balance sheet transactions, assumptions for pro formas, and
stock transactions of corporate officers. Although SOX did
not have provisions directly dealing with healthcare, this
act affected the healthcare industry, as every publicly held
company involved with healthcare would have to undergo
significant restructuring of their accounting practices. Propo­
nents contend that such legislation was essential to strengthen
accounting controls and restore investor confidence, while
opponents cite the overly complex oversight necessary for
compliance, leading to reduced competitiveness with foreign
businesses.
American Recovery and Reinvestment
Act, 2009
As the United States headed into the worst recession since the
Great Depression, Congress passed the American Recovery
and Reinvestment Act, in an attempt to create jobs, promote
investment, and induce consumer spending.40 Because the
Federal Reserve had already decreased interest rates to zero,
with little effect on the credit markets, fiscal policy was chosen
over monetary policy as a plan to stimulate the economy, and
therefore an infusion of government capital – $787 billion –
was utilized to bridge the output gap created by a fall in
consumer spending. Although the majority of the capital was

60
CHAPTER 5 • Business principles for plastic surgeons
Practice and preparation are the keys to success. The field of
negotiation, as an academic discipline, is a rich body of work
that incorporates game theory, auction strategies, psychology,
and behavioral economics. Perhaps the seminal work in this
field is Getting to Yes: Negotiating Agreement Without Giving In
by Fisher, Ury, and Patton.44 The two overriding principles
are: 1) knowing what you want versus what you need and 2)
knowing what your opponent wants and needs. Negotiating
begins with considerable preparation, not just predicting
what your opponent will do, as if in a chess match, but what
your opponent requires to improve his or her position. In fact,
both opponents in a two-party negotiation may not even
know what their best position is or why a certain solution may
be favorable for each other. Creativity and communication are
critical for success.
Negotiation, then, begins by developing and articulating
your BATNA: the best alternative to a negotiated agreement.
This is the walk-away position if no agreement can be reached,
or “the lowest you will go”, which should be ascertained
before the negotiation begins. After deciding that you will not
bargain over these positions, utilize the following four prin­
ciples: 1) separate the people from the problem; 2) focus on
interests and not positions; 3) invent options for mutual gain;
4) insist on using objective criteria.45–49
These concepts of “principled” negotiation work most of
the time. Occasionally, however, negotiation reaches an
impasse, and breakthrough can be achieved by reframing the
problem. Specifically, avoid escalation by not reacting, arguing,
rejecting, or pushing. Step out of the situation, help the other
side view the problem objectively, and reframe the problem
from their perspective. Determine what options will provide
mutual gain, or at the very least, minimize losses. In other
words, pick your battles wisely. Concession is not failure, but
often resets the parameters of the problem, so that future itera­
tions of the “game” may yield an outcome in your favor.
Particularly difficult negotiations involve those individuals
or groups who will not compromise over their demands, who
have an asymmetry of information, who are unwilling to view
the problem from your perspective, or who threaten to use
power to enforce their solution. People who fall into this
category are the schoolyard bully, an impaired physician,
sociopaths, terrorists, and sometimes the “difficult patient”,
who may have an underlying body dysmorphic disorder. One
BOX 5.11  Idea watch: legal and regulatory considerations
Reference: Thacker PD. Consumers deserve to know who’s funding
health research. Harvard Business Review online, December 2,
2014;
-funding-health-research#75
Serving as the lead investigator for Senator Charles Grassley,
who co-authored the Physician Payments Sunshine Act of 2010 (an
amendment to the ACA), Paul Thacker helped to expose previously
undisclosed payments made by drug and device manufacturers to
doctors and teaching hospitals, over the course of several decades.
While much of this funding could be considered legitimate, to
support research and education, much of the funding was not,
covering such activities as the ghost writing of scientific
publications, public speaking events in which content was biased,
and kickbacks for using specific drugs and devices.
Perhaps the most important ramification of this legislation, which
requires that industry report all financial transactions with physicians,
is the improved transparency of this relationship, such that real and
potential conflicts of interest can be identified. Optics matter. In
exchange for our right to self-regulate as professionals, physicians
must apply our specialized knowledge and skill to the greater
societal good, conforming to a body of ethics that is built on
honesty and integrity.
Thacker’s hope is that given medicine’s leadership position in
disclosing industry funding, it is time for physicians to lead their
other colleagues in science to ensure that all scientific work remains
transparent and independent. While the Sunshine Act remains
controversial, and long-term effects are not known, there has been a
shift toward transparency at the intersection of industry and
medicine. We now recognize that all physicians face conflicts of
interest, which should be managed proactively, if possible.
Negotiation
“You can’t always get what you want, but if you try sometime,
you just might find, you get what you need.”
Mick Jagger and Keith Richards
Negotiation (Box 5.12) can be defined as “a dialogue intended
to resolve disputes, to produce an agreement upon courses of
action, to bargain for individual or collective advantage, or to
craft outcomes to satisfy various interests”.43 Whenever a
decision is made, negotiation occurs. If a surgeon decides to
start a laser practice, he or she must examine the opportunity
cost in pursuing that service and negotiate, with the stake­
holders of his or her practice – receptionists, nursing staff,
patients – how this change will impact the practice. If a junior
partner wants to develop a microsurgical breast reconstruc­
tion practice, he or she must negotiate with the hospital for
more operative block time, carve out with insurance compa­
nies a more favorable reimbursement schedule, and gain the
blessing of the senior partners, who will have to cover these
patients when the primary surgeon is not available and absorb
these low margin cases into their revenue stream. If an aca­
demic plastic surgery practice wishes to develop and build an
outpatient aesthetic center with procedural rooms, the divi­
sion chief must perform a complex negotiation with multiple
parties (the Dean, Chairs, hospital administrators), over
multiple iterations, regarding multiple issues.
Although some individuals are blessed with excellent
empathic and communication skills and can negotiate suc­
cessfully, negotiation is a discipline that can be learned.
BOX 5.12  Idea watch: negotiation
Reference: Mikes A, Hall M, Millo Y. How experts gain influence.
Harvard Business Review. 2013;91:70–74.76
Is it better to be loved or feared? Effective negotiation can be
accomplished by following a set of rules and guidelines, but how
does one achieve influence on the decision-making of others?
Projecting strength and warmth surely helps in the art of persuasion,
but the authors of this paper identified four competencies that allow
individuals to gain personal and organizational-wide influence:
• Trailblazing: finding new opportunities to use expertise
• Toolmaking: developing and deploying tools that embody and
spread expertise
• Teamwork: using personal interaction to take in others’ expertise
and convince people of the relevance of your own
• Translation: personally helping decision-makers understand
complex content

61
Ethics
Just as ethics helps to guide decision-making in healthcare,
so too should ethics play a major role in the choices made by
business entities. The history of ethics and capitalism is quite
fascinating. Adam Smith, who published The Wealth of Nations
in 1776, argued that markets were guided by “the invisible
hand” to produce the right amount of goods for society, but
that such a force was intimately tied to our ethical obligations
to each other.52 Andrew Carnegie and other industrialists from
the 1800s articulated the need for business to pursue charity
and stewardship, both forms of social philanthropy, because
with power comes responsibility. Even Milton Friedman, the
Nobel-winning economist from the University of Chicago,
who believed that the only ethical obligation of business is to
maximize profits, emphasized that business efficiently creates
BOX 5.13  Idea watch: ethics
Reference: Anderson M, Escher P. The MBA Oath: Setting a Higher
Standard for Business Leaders. New York: Portfolio Hardcover, the
Penguin Group; 2010.
In response to several highly publicized business scandals of the
early 2000s, academic leaders in business management have come
forward to develop the MBA Oath.53 The integrity of business, as a
“profession”, was seriously compromised, involving fraudulent
accounting (Enron), Ponzi schemes (Bernie Madoff), excessive
executive compensation (widening of the salary gap between
leadership and labor), business–government collusion (the revolving
door between academia, Wall Street, and the Federal Reserve), and
illegal derivative trading (one of the many causes of the Great
Recession of 2008–2009). Similar to the Hippocratic Oath for
physicians, this pledge acknowledges that management is a
profession bound by ethical principles.
The MBA Oath
As a business leader I recognize my role in society.
• My purpose is to lead people and manage resources to create
value that no single individual can create alone.
• My decisions affect the well-being of individuals inside and
outside my enterprise, today and tomorrow.
Therefore, I promise that:
• I will manage my enterprise with loyalty and care, and will not
advance my personal interests at the expense of my enterprise
or society.
• I will understand and uphold, in letter and spirit, the laws and
contracts governing my conduct and that of my enterprise.
• I will refrain from corruption, unfair competition, or business
practices harmful to society.
• I will protect the human rights and dignity of all people affected
by my enterprise, and I will oppose discrimination and
exploitation.
• I will protect the right of future generations to advance their
standard of living and enjoy a healthy planet.
• I will report the performance and risks of my enterprise
accurately and honestly.
• I will invest in developing myself and others, helping the
management profession continue to advance and create
sustainable and inclusive prosperity.
In exercising my professional duties according to these
principles, I recognize that my behavior must set an example of
integrity, eliciting trust and esteem from those I serve. I will remain
accountable to my peers and to society for my actions and for
upholding these standards.
This oath I make freely, and upon my honor.
option is to not negotiate – step away from the situation – and
use other means to resolve a dispute, such as legal action.
However, skilled negotiators can still deal with these chal­
lenging situations effectively, by using uncertainty, chaos, and
ambiguity to disarm opponents and neutralize their position.
Successful negotiators can translate little gains into positive
momentum, by focusing on future rounds of the negotiation
and setting up more effective positions for the future.
Ethics
“Always do right, this will gratify some people and astonish the
rest.”
Mark Twain
In healthcare, we are faced with multiple challenges that test
our ethical grounding (Box 5.13). Healthcare providers must
make numerous decisions regarding patient care every day,
and society rightfully expects these providers to behave ethi­
cally. Competency in patient care and medical knowledge is
required but not sufficient; providers must also demonstrate
competency in interpersonal and communication skills,
systems-based practice, practice-based learning, and profes­
sionalism, all of which involve a firm commitment toward
ethical practice. So important are these competencies that
medical education, residency training programs, state licen­
sure, board certification and maintenance of certification, and
hospital credentialing incorporate these elements in evaluat­
ing healthcare providers.
John Canady, past president of the American Society of
Plastic Surgeons and former chair of its Ethics Committee,
observed, “Plastic surgeons who are aware of competing
interests that influence their decision-making processes stand
a greater chance of achieving ethical outcomes. Nevertheless,
with the growing volume of non-reimbursed care and expec­
tations of perfect outcomes, achieving uniformly ethical
decisions without burdensome self-sacrifice is difficult at
best”.50 Competing factors that influence decision-making for
plastic surgeons include personal finances (ownership of
surgery centers, selection of procedures, pricing), regulatory
forces (Emergency Medical Treatment and Active Labor Act
(EMTALA), Joint Commission on Accreditation of Healthcare
Organizations (JCAHO), American Association for Accredita­
tion of Ambulatory Surgery Facilities (AAAASF)/Accredita­
tion Association for Ambulatory Healthcare (AAAHC),
Occupational Safety and Health Administration (OSHA), and
Health Insurance Portability and Accountability Act (HIPAA)
– to name just a few, and professional duty (informed consent,
discussion of error).
When faced with a dilemma, healthcare providers must
incorporate intuition and reasoning into making a decision.
Resolution of an ethical question often requires careful con­
sideration of culture, infrastructure, leadership/governance,
and personal integrity. Ethical intelligence can be developed.
In his book Strengthening Ethical Wisdom, Jack Gilbert argues
that intentions, manifest by vision, mission, values, strategy,
and goals, directly impact performance.51 In healthcare, this
translates into patient safety, quality of care, productivity and
throughput, patient and employee satisfaction, reputation,
and financial health. Medical ethics is practical, case-based,
and relative to the context of the situation.

62
CHAPTER 5 • Business principles for plastic surgeons
and allocates wealth in society if the stakeholders are honest,
transparent, and just.
Today, business ethics is just good business. A new para­
digm for delivering stakeholder value has replaced the
previous model of maximizing shareholder returns. Because
suppliers, customers, employees, competitors, and com­
munities are all affected by the decisions of a business, a
stakeholder-approach to organizational structure maps out
these relationships and attempts to align competing interests,
to maximize value creation of the networks, products, ser­
vices, and information. Most business leaders are aware
that values, rights, duties, and responsibilities must inform
decision-making, much like these principles affect medical
ethics. Consequences may not only have legal ramifications
but may also impact the bottom line. Values-based capitalism
strives to maximize stakeholder wealth by trying to humanize
the institution of business and encourage stakeholders to
perform at their best, not their worst. Key principles of values-
based capitalism include: stakeholder cooperation, shared
responsibility, recognition of complexity, continuous creation,
and emergent competition.
Leadership
“The greatest accomplishment is not in never failing, but in
rising again after you fall.”
Vince Lombardi
The most concise answer to the question “what defines a
leader?” is “someone who has followers.” The real question,
though, should be framed as follows: “what defines a great
leader?” This answer is quite elusive, depending upon the
leader, the context, and the constituents (Box 5.14).54
In business, leaders must first and foremost be effective
managers (Fig. 5.9). “The manager is the dynamic, life-giving
element in every business. Without leadership, the ‘resources
of production’ remain resources and never become produc­
tion. In a competitive economy, above all, the quality and
performance of its managers determine the success of the
business, indeed they determine its survival. For the quality
and performance of its managers is the only effective advan­
tage an enterprise in a competitive environment can have.”
So begins The Practice of Management, published in 1954 by
Fig. 5.9  Leadership: leading the new venture.
Managing
superiors
Managing
oneself
Managing teams
Managing culture
Managing
direct
reports
Peter Drucker, considered to be an early, defining modern
work on management theory and practice.55,56
Although managers differ from leaders along many param­
eters, the skill sets of both are complementary and, when
combined, provide synergy that enhances the strength of an
organization:57–62
Managers administer
Leaders innovate
Managers ask how and
when
Leaders ask what and why
Managers imitate
Leaders originate
Managers focus on systems
Leaders focus on people
Managers maintain
Leaders develop
Managers rely on control
Leaders rely on trust
Managers accept the status
quo
Leaders challenge the status
quo
Managers look at the
bottom line
Leaders look toward and past
the horizon
Managers do things right
Leaders do the right thing
Managers operate
Leaders strategize
But, managers often lead
Leaders often manage
Drucker continues, “To succeed in this new world, we will
have to learn, first, who we are… Success in the knowledge
economy comes to those who know themselves – their
strengths, their values, and how they best perform”. Individu­
als must determine where they belong and what they should
contribute. In this age of discontinuity, where information has
become as valuable as capital, and communication is critical
to the flow of adding value, individuals must manage their
own careers, carving out discrete niches, keeping themselves
engaged, and knowing when to change course.
For leadership to be effective, the individual uses social
influence to gain the support of followers, through posi­
tional, personal, and relational power, to accomplish a
common goal. Many theories have been proposed to describe
exactly how leadership works, but ultimately leaders must
be responsible for a number of functions, such as delegation,
empowerment, negotiation, conflict resolution, innovation,
inspiration, and guiding change. Through a variety of lead­
ership styles – forcing, avoiding, compromising, accommo­
dating, and collaborating – leaders must also learn how to
“manage from the middle”. Serving as a conduit for transfer
of information, knowledge workers today must manage up
and down, both their supervisors and their direct reports.
Those who can effect change in such an environment are
incredibly influential, adding value to the human capital of
an organization.
Perhaps the most critical function of a leader is the building
of high-functioning, high-performing teams. Teamwork has
become increasingly important in business, because of several
factors: environmental complexity and pace, the dependence
upon internal and external partners, the need for multiple
sources of information, and the desire to have varied perspec­
tives and diverse thought. The smartest of us is not as smart
as all of us. Teams, however, do not automatically form and
function smoothly. An effective leader builds collaborative
teams that deliver results by establishing the following char­
acteristics: goal compatibility, trust and commitment, interde­
pendence and accountability, open communication and
acceptance of ideas, and converting conflict into creativity.
The leader also serves as the team’s advocate, gaining support
from senior executives, providing the necessary resources to

63
Leadership
The ultimate challenge of any leader is to take their orga­
nization from “good to great”. Jim Collins identified 11 pub­
licly traded, stable companies that experienced substantial,
sustained growth, as defined by financial performance several
multiples better than the competitors in their industry.58
Collins identified specific factors responsible for helping
transition from “good to great”: focusing on core competen­
cies, forging a culture of discipline, finding the right people
to figure out where to go, confronting the brutal facts while
maintaining hope, using technology accelerators, and creating
momentum from the additive effect of small initiatives. What
all of these companies had in common, though, was Level 5
leadership: CEOs who had personal humility and professional
will. The most effective leaders were not outspoken and
charismatic, but rather humble, selfless individuals who dis­
played fierce resolve in delivering the company’s value
proposition. Integrity and vision matter; these qualities confer
upon the leader the ability to transform an organization from
good to great.
Acknowledgments
This work was supported by the Ethel F. and James B. Valone Plastic
Surgery Research Endowment, at the University of North Carolina. The
author wishes to thank Suzanne, Chloe, Hank, and Timo, for their uncon­
ditional love and support. Oh, the places we will go.
solve the problem, and keeping stakeholders informed. It
turns out that being an effective team leader has less to do
with technical knowledge and more to do with emotional
intelligence and communication skills.61
Kouzes and Posner offer a simple but extremely helpful
model of leadership in which credibility serves as the founda­
tion for all future success. Having studied hundreds of leaders
across many types of disciplines, they provide these recom­
mendations for becoming a great leader: 1) model the way –
clarify values and set the example; 2) inspire a shared vision
– envision the future and enlist others; 3) challenge the process
– search for opportunities, experiment, and take risks; 4)
enable others to act – foster collaboration and strengthen
others; and 5) encourage the heart – recognize contributions
and celebrate the values and victories.60 This model dispels
the myth that “it is lonely at the top”, because the goal of
leadership should be to bring everyone to the top.
Leadership at the very top – CEOs of large, complex orga­
nizations – no doubt requires social influence to achieve goals,
but this type of leadership also contains unique challenges
that require unique skills, to deliver effective direction and
strategy, organizational structure, selection of people, and
appropriate incentives. Porter and Nohria examined 110
newly appointed CEOs from mostly public companies, with
median revenue of $3.7 billion.54 Average age at appointment
was 49.7 years, and average time with the company had been
14.1 years. Seventy-five percent of these CEOs had been inside
candidates, and 64% had a graduate-level degree.
The findings were surprising. Challenges specific to their
new role as CEO included broader scope than anticipated,
placating the Board of Directors, constraints in power, diffi­
culty obtaining reliable information, maintaining visibility,
having to produce within a limited time horizon, and expecta­
tions of change by the stakeholders. These CEOs discovered,
however, that indirect levers could be quite powerful, by
shaping context so that members of the organization could
make good decisions, take appropriate action, and advance the
mission of the company. Other interesting findings included:
Time spent working on issues internal to the company: 69%
Time allocated to core agenda items:
52%
Time spent in face-to-face communication:
81%
Time spent with constituents other than direct reports:
42%
Time spent communicating with groups:
63%
Based upon these observations, specifically that indirect levers
of influence may be more important than direct levers, Porter
and Nohria recommend that CEOs pay special attention to
allocating their most limited, yet crucial resource: their pres­
ence. CEOs – and perhaps all leaders – can manage their
presence by setting a clear personal agenda, communicating
relentlessly, gathering information continuously, leveraging
symbolism, and harnessing the power of a strong manage­
ment team. Establishing legitimacy, through competence,
fairness, results, and integrity, instills confidence in the stake­
holders, who are then empowered to do their best.
BOX 5.14  Idea watch: leadership
Reference: Goleman D. The focused leader: how effective
executives direct their own – and their organizations’ – attention.
Harvard Business Review. 2013;91:50–60.78
Dan Goleman introduced the idea that effective leaders must
have emotional intelligence, but he now adds the skill of focus to
the list of qualities that distinguish the best leaders. He points out
that a primary task of leadership is to direct attention, and as such,
the leader must first learn to focus his or her own attention.
Furthermore, the concept of focusing is not just filtering out
distractions, but rather concentrating on different topics, in different
ways, for different purposes. Goleman cites recent neuroscience
research that shows that focus is a complex cognitive function that
draws upon the integration of multiple neural pathways.
To be effective and sharpen one’s focus, every leader must
cultivate an awareness of self and others. Both inward and outward
focus are necessary to develop one’s emotional intelligence.
Self-awareness and self-control increase one’s ability to focus on
others. Social relationships are dependent upon directing attention
toward others, and empathy emerges as the critical trait that is the
hallmark of a natural leader, regardless of organizational or social
rank. Goleman notes that the most effective leaders actually exhibit
three types of empathy:
1. Cognitive empathy – the ability to understand another person’s
perspective
2. Emotional empathy – the ability to feel what someone else feels
3. Empathic concern – the ability to sense what another person
needs from you.

64
CHAPTER 5 • Business principles for plastic surgeons
7. Kim C, Mauborgne R. Blue Ocean Strategy. Boston: Harvard
Business Press; 2005.
8. Berman K, Knight J, Case J. Financial Intelligence: A Manager’s Guide
to Knowing What the Numbers Really Mean. Boston: Harvard Business
Press; 2013. In my opinion, this is the most concise, readable, and
applicable text on accounting and finance. I found this book after getting
my MBA. If you want to understand the numbers of business, read this
book now!
37. Christensen C, Grossman JH, Hwang J. The Innovator’s Prescription:
A Disruptive Solution for Health Care. New York: McGraw Hill;
2009. These experts in innovation approach healthcare as an industry that
must be disrupted and rebuilt. Results pending.
38. Porter ME, Teisberg EO. Redefining Health Care: Creating Values-Based
Competition on Results. Boston: Harvard Business Press;
2006. Healthcare is a business that exists in a highly competitive
environment. The reform that we currently need may come from
restructuring our competitive models to create new value, for patients and
providers.
44. Fisher R, Ury W, Patton B. Getting to Yes: Negotiating Agreement
Without Giving In. 2nd ed. New York: Penguin Books; 1991.
54. Nohria N, Khurana R. Handbook of Leadership Theory and Practice.
Boston: Harvard Business Press; 2010.
58. Collins J. Good to Great: Why Some Companies Make the Leap… and
Others Don’t. New York: Harper Business; 2001.
63. Topol E. The Creative Destruction of Medicine: How the Digital
Revolution Will Create Better Health Care, 2013. New York: Perseus
Books Group; 2013. Cardiologist, genomic researcher, and member of the
digerati, Eric Topol is a modern-day Da Vinci who has written the best
book about healthcare since Paul Starr’sThe Social Transformation of
American Medicine, in 1982. Topol explains why medicine is poised for
inconceivably disruptive innovation, due to “a propitious convergence of a
maturing internet, ever-increasing bandwidth, near-ubiquitous
connectivity, and remarkable miniature pocket computers in the form of
mobile phones”.
64. Brill S. America’s Bitter Pill: Money, Politics, Backroom Deals, and the
Fight to Fix Our Broken Healthcare System. New York: Random
House; 2015. You may think you know the story of Obamacare, but you
do not know the whole story until you read Stephen Brill’s riveting (yes,
riveting) account of the rise and fall and rise of the Affordable Care Act.
Access the complete reference list online at

64.e1
References
References
1. <
_States>.
2. Porter M. On Competition. Boston: Harvard Business Press; 2008.
3. Drucker PF. Managing for Results: Economic Tasks and Risk-Taking
Decisions. New York: Harper Collins; 1964.
4. Drucker PF. Managing the Nonprofit Organization: Principles and
Practice. New York: Harper Collins; 1990.
5. Drucker PF. Managing in Turbulent Times. New York: Harper Collins;
1980.
6. Johnson MW. Seizing the White Space: Business Model Innovation for
Growth and Renewal. Boston: Harvard Business Press; 2010.
7. Kim C, Mauborgne R. Blue Ocean Strategy. Boston: Harvard
Business Press; 2005.
8. Berman K, Knight J, Case J. Financial Intelligence: A Manager’s Guide
to Knowing What the Numbers Really Mean. Boston: Harvard Business
Press; 2013. In my opinion, this is the most concise, readable, and
applicable text on accounting and finance. I found this book after getting
my MBA. If you want to understand the numbers of business, read this
book now!
9. Stickney CP, Weil RL. Financial Accounting: An Introduction to
Concepts, Methods, and Uses. 12th ed. Mason, OH: Thomson
Southwestern; 2007.
10. Jiambalvo J. Managerial Accounting. 3rd ed. Hoboken, NJ: John
Wiley & Sons; 2007.
11. Hawawini G, Viallet C. Finance for Executives: Managing for Value
Creation. 3rd ed. Mason, OH: Thomson Southwestern; 2007.
12. Baye MR. Managerial Economics and Business Strategy. 5th ed. New
York: McGraw Hill; 2006.
13. Corts KS, Rivkin JW. A note on microeconomics for strategists. Harvard
Business School Case Brief, January 2000.
14. <>.
15. Krugman PR, Obstfeld M. International Economics: Theory and Policy.
7th ed. Boston: Pearson Addison Wesley; 2005.
16. Kotler P, Keller KL. Marketing Management. 12th ed. Upper Saddle
River, NJ: Pearson Prentice Hall; 2006.
17. Moore GA. Crossing the Chasm. Marketing and Selling Disruptive
Products to Mainstream Customers. New York: Harper Collins
Business Essentials; 1991.
18. Cachon G, Terwiesch C. Matching Supply with Demand: An
Introduction to Operations Management. New York: McGraw Hill;
2006.
19. Goldratt E, Cox J. The Goal: A Process of Ongoing Improvement and the
Theory of Constraints. Great Barrington, MA: North River Press;
2004.
20. Heskett JL, Jones TO, Loveman GW, et al. Putting the service-profit
chain to work. Harv Bus Rev. 1994.
21. Jones TO, Sasser WE. Why satisfied customers defect. Harv Bus Rev.
1995.
22. Drucker PF. Innovation and Entrepreneurship. New York: Harper
Collins; 1985.
23. Mathes SJ. Innovation. Plast Reconstr Surg. 2007;120:2110–2111.
24. Krummel TJ. Inventing our future: training the next generation of
surgeon innovators. J Pediatr Surg. 2009;44:21–35.
25. Christensen CM. The Innovator’s Dilemma. New York: Harper Collins
Business Essentials; 1997.
26. Kaplan JM, Warren AC. Patterns of Entrepreneurship. 2nd ed.
Hoboken NJ: John Wiley & Sons; 2007.
27. Porter ME, Kramer MR. Strategy and society: the link between
competitive advantage and corporate social responsibility. Harv Bus
Rev. 2006.
28. McDonough W, Braungart M. Cradle to Cradle: Remaking the Way We
Make Things. New York: North Point Press; 2002.
29. Sachs JD. The End of Poverty: Economic Possibilities for Our Time. New
York: Penguin Press; 2005.
30. Yunus M. Creating a World Without Poverty: Social Business and the
Future of Capitalism. New York: Perseus Books Group; 2007.
31. Hawken P, Lovins A, Lovins LH. Natural Capitalism: Creating the
Next Industrial Revolution. New York: Little, Brown; 1999.
32. Esty DC, Winston AS. Green to Gold: How Smart Companies Use
Environmental Strategy to Innovate, Create Value, and Build a
Competitive Advantage. New Haven, CT: Yale University Press;
2006.
33. <>.
34. <>.
35. Fried BJ, Fottler MD. Human Resources in Healthcare: Managing for
Success. 3rd ed. Chicago: Health Administration Press; 2008.
36. Pozgar GD. Legal Aspects of Health Care Administration. 10th ed.
Sudbury: Jones and Bartlett Publishers; 2007.
37. Christensen C, Grossman JH, Hwang J. The Innovator’s Prescription:
A Disruptive Solution for Health Care. New York: McGraw Hill;
2009. These experts in innovation approach healthcare as an industry that
must be disrupted and rebuilt. Results pending.
38. Porter ME, Teisberg EO. Redefining Health Care: Creating Values-
Based Competition on Results. Boston: Harvard Business Press;
2006. Healthcare is a business that exists in a highly competitive
environment. The reform that we currently need may come from
restructuring our competitive models to create new value, for patients
and providers.
39. <>.
40. <>.
41. <
Patient_Protection_and_Affordable_Care_Act>.
42. <
Dodd–Frank_Wall_Street_Reform_and_Consumer_Protection_Act>.
43. <>.
44. Fisher R, Ury W, Patton B. Getting to Yes: Negotiating Agreement
Without Giving In. 2nd ed. New York: Penguin Books; 1991.
45. Ury W. Getting Past No: Negotiating in Difficult Situations. New York:
Bantam Dell Books; 1993.
46. Subramanian G. Negotiauctions: New Dealmaking Strategies for a
Competitive Marketplace. New York: WW Norton and Co; 2010.
47. Sebenius JK. Six habits of merely effective negotiators. Harv Bus
Rev. 2001.
48. Patterson K, Grenny J, McMillan R, Switzler A. Crucial
Conversations: Tools for Talking When Stakes are High. New York:
McGraw Hill; 2002.
49. Patterson K, Grenny J, McMillan R, Switzler A. Crucial
Confrontations: Tools for Resolving Broken Promises, Violated
Expectations, and Bad Behavior. New York: McGraw Hill;
2005.
50. Zbar RIS, Taylor LD, Canady JW. Ethical issues for the plastic
surgeon in the tumultuous health care system: dissecting
the anatomy of a decision. Plast Reconstr Surg. 2008;122:
1245–1258.
51. Gilbert JA. Strengthening Ethical Wisdom: Tools for Transforming Your
Health Care Organization. Chicago, IL: Health Forum Inc., American
Hospital Association Press; 2007.
52. Cohn KH, Hough DE. The Business of Health Care. Volumes 1–3.
Westport, CT: Praeger Press; 2008.
53. <>. Signed by the author on the same day,
signatory #4721.
54. Nohria N, Khurana R. Handbook of Leadership Theory and Practice.
Boston: Harvard Business Press; 2010.
55. Drucker PF. The Practice of Management. New York: Harper Collins;
1954.
56. Drucker PF. The Effective Executive: The Definitive Guide to Getting the
Right Things Done. New York: Harper Collins; 1967.
57. Whetton DA, Cameron KS. Developing Management Skills. 6th ed.
Upper Saddle River, NJ: Pearson Prentice Hall; 2005.
58. Collins J. Good to Great: Why Some Companies Make the Leap… and
Others Don’t. New York: Harper Business; 2001.
59. Bennis W. On Becoming a Leader. New York: Perseus Books Group;
1989:2009.
60. Kouzes JM, Posner BZ. The Leadership Challenge. 4th ed. San
Francisco: Jossey-Bass; 2007.

64.e2
CHAPTER 5 • Business principles for plastic surgeons
61. Gratton L, Erickson TJ. Eight ways to build collaborative teams.
Harv Bus Rev. 2007.
62. McGinn KL, Long-Lingo E. Power and influence: Achieving your
objectives in organizations. Harvard Business School Case Brief, April
2002.
63. Topol E. The Creative Destruction of Medicine: How the Digital
Revolution Will Create Better Health Care, 2013. New York: Perseus
Books Group; 2013. Cardiologist, genomic researcher, and member of the
digerati, Eric Topol is a modern-day Da Vinci who has written the best
book about healthcare since Paul Starr’s The Social Transformation of
American Medicine, in 1982. Topol explains why medicine is poised for
inconceivably disruptive innovation, due to “a propitious convergence of a
maturing internet, ever-increasing bandwidth, near-ubiquitous
connectivity, and remarkable miniature pocket computers in the form of
mobile phones”.
64. Brill S. America’s Bitter Pill: Money, Politics, Backroom Deals,
and the Fight to Fix Our Broken Healthcare System. New York:
Random House; 2015. You may think you know the story of Obamacare,
but you do not know the whole story until you read Stephen Brill’s
riveting (yes, riveting) account of the rise and fall and rise of the
Affordable Care Act.
65. Raynor ME, Ahmed M. Three rules for making a company truly
great. Harv Bus Rev. 2013;91:108–117.
66. Kaplan RS, Porter ME. How to solve the cost crisis in health care.
Harv Bus Rev. 2011;89:46–64.
67. McGrath RG. Transient advantage: strategy for turbulent times.
Harv Bus Rev. 2013;91:62–70.
68. Kaplan RS, Porter ME. Motivating salespeople: what really works.
Harv Bus Rev. 2011;90:71–75.
69. Avery J, Fournier S, Wittenbraker J. Unlock the mysteries of your
customer relationships. Harv Bus Rev. 2014;92:72–81.
70. Porter ME, Lee TH. The strategy that will fix health care. Harv Bus
Rev. 2013;10:50–70.
71. Christensen CM, Raynor M, McDonal R. One more time: what is
disruptive innovation? Harv Bus Rev. 2015;93:44–53.
72. Isaacson W. The real leadership lessons of Steve Jobs. Harv Bus Rev.
2012;90:92–102.
73. Porter ME, Kramer MR. Creating shared value. Harv Bus Rev.
2011;89:62–67.
74. Fernandez-Araoz C. 21st century talent spotting: why potential now
trumps brains, experience, and “competencies.”. Harv Bus Rev.
2014;92:46–56.
75. Thacker PD. Consumers deserve to know who’s funding health research.
Harvard Business Review online; <
consumers-deserve-to-know-whos-funding-health-research#>; 2014.
76. Mikes A, Hall M, Millo Y. How experts gain influence. Harv Bus
Rev. 2013;91:70–74.
77. Anderson M, Escher P. The MBA Oath: Setting a Higher Standard for
Business Leaders. New York: Portfolio Hardcover, the Penguin
Group; 2010.
78. Goleman D. The Focused Leader: How Effective Executives Direct
Their Own—And Their Organizations’—Attention. Harv Bus Rev.
2013;91:50–60.

6 
Medico-legal issues in plastic surgery
Neal R. Reisman
SYNOPSIS
■ Plastic surgeons will have a significant interaction with attorneys
as they care for the injured, abused, and possibly negligently
treated.
■ Informed consent is a process, not merely a signed document.
■ An express warranty may be established by including in the record a
photo the patient believes will be the result.
■ Fraud and abuse claims have NO statute of limitations and are not
covered by liability insurance.
■ HIPAA is created to protect patient privacy and covers medical records
and photography.
■ Agency Law places responsibility on the employer for employee
negligence when performing work-related duties.
■ Divulging patient information in a blog or social media website is an
HIPAA violation.
■ It is critical to notify your liability carrier as soon as possible if you
receive notice of a lawsuit against you.
■ Physicians who basically share an office may each be exposed to
liability in caring for patients.
■ Patient selection, when proper and appropriate, is the best method to
avoid a negligence claim against you.
Introduction
Plastic surgeons have many interactions with the legal system.
While medicine has many nuances and inferences, the law is
steeped in legal doctrine, and the written word. An impres­
sion causing considerable concern is that if something is not
recorded and written, it never occurred. The practice of medi­
cine is filled with usual actions that may not be specifically
documented, leading to a major conflict between medicine
and the law. This chapter will focus on the interactions
between plastic surgeons and the legal system and also
methods of reducing medico-legal risk and improving patient
safety. Areas of the law will be presented and its impact on
plastic surgical practice will be emphasized.
Interactions with attorneys and the
legal system
Plastic surgeons can have a significant interaction with the
legal system through their care of patients, which through
injury and disease, may lead to legal representation. Work-
related injuries, auto-accidents, animal bites, and domestic
abuse often will initiate a lawsuit. The physician will partici­
pate in documenting injury, future medical expenses, and
commenting on disability and scarring usually through a
deposition and occasionally live testimony at trial. There are
those who abhor any interaction with attorneys, but realisti­
cally many feel it appropriate to participate in the legal system
and certainly represent and assist their patient. There are
some guidelines and rules to follow. The Health Insurance
Portability and Accountability Act (HIPAA) now requires
written consent before you can discuss any patient informa­
tion with anyone outside of the medical treatment area. An
attorney acting within ethical guidelines will provide you
with an authorization by their client and your patient to
discuss the patient’s care and treatment. You are prohibited
from discussing the patient’s information without such autho­
rization. Do not be fooled by legal-appearing or court-initiated
papers that seem to override written approval. Ask the attor­
ney for authorization and confirm with your patient as neces­
sary. If a deposition is required, assure that you have proper
written authorization.
It has also been suggested if you are hired as an expert, that
you seek advanced payment for your time and establish a
written agreement that if the deposition is canceled more than
2 weeks from the scheduled date, you will refund the payment.
If the deposition is canceled in the second week, then one half
of the payment will be refunded, and if it is canceled closer

66
CHAPTER 6 • Medico-legal issues in plastic surgery
utilized for informed consent. A few states utilize the reason­
able “doctor standard”, which states that information a rea­
sonable physician thinks is important must be presented to a
patient for their informed consent. More commonly, a reason­
able “patient standard” is used. The standard states that all
information a reasonable patient would want and need to
know should be presented as they make their informed choice.
There is much confusion about how much information should
be outlined and in what fashion. There are those who believe
the informed consent process should be videotaped as there
is always a question after-the-fact about what was discussed
or presented. This is usually unnecessary as documentation
should include the process of information presented, ques­
tions asked and answered, and finally an understanding of
what the physician can and cannot do. There are many styles
of learning and current thinking is to include three styles
during the informed consent process. There are visual learn­
ers, auditory learners, and kinesthetic learners. The visual
learner would want to see a picture, photograph, or some
demonstrative example of what is being proposed. The
auditory learner wants to listen very carefully to recom­
mendations, the surgical procedure, pre- and postoperative
instructions, reasonable expectations, alternatives to care, and
inherent risks and complications. The kinesthetic learner is
looking for how all of this affects them personally. The goal
of informed consent is reaching high levels of understanding,
which may be reached by combining all three learning styles
throughout the process of informed consent. It is not a signed
document itself, but the process of understanding documented
by the consent. I believe the surgeon has a responsibility to
outline the risks and hazards of the proposed procedure. It is
also suggested to develop a team of surgeon, nurse, coordina­
tor, and others to achieve this goal. There are some patients
who never reach a complete understanding of the informed
consent process and it is recommended that surgery then
should not proceed. It is also recommended that multiple
visits and discussions be utilized allowing appropriate time
for discussions at home, reflection on goals, and adequate
questions to be answered before proceeding with a nonemer­
gent procedure.
Privacy law
Privacy law is intended to protect patient information. This
includes their medical information, photographs, lab results
and correspondence. HIPAA covers many protections for the
patient. The practice has an obligation to explain and docu­
ment the patient’s understanding and acceptance. There is a
duty to secure their information, and even pursue those who
violate such protections. The practice will have an obligation
under new “red flag rules” to check identity of patients with
their coverage, further protecting the patient against identity
theft. The plastic surgery office must be careful when using
patient information or photography in a commercial way,
such as on a website, advertisement or patient outcome
booklet, shown to prospective patients. A breach of privacy is
not covered by your malpractice insurance and any judg­
ments as a result of this breach must come from you alone
and not your insurance company. It is not unusual to have a
claim joined to a negligence claim that patient information
was not protected. This often adds to the stress of a lawsuit
and may add incentives to settle the claim. If you have patient
to the scheduled time, the payment will be forfeited. Establish
an hourly rate and seek 2 hours in advance. It is also wise
to schedule a deposition at the end of the day and not in
the middle, which could significantly interfere with patient
scheduling.
Legal interactions: depositions and narratives
Much of the correspondence between the plastic surgery
practice and an attorney may be in their request for an official
narrative outlining care, past treatments, future concerns, and
specific questions the attorney might pose. The medical nar­
rative should be factual and list what sources are used and
what the report is based on. One should be honest in describ­
ing past and future concerns and not be too overreaching or
inadequate in description. It is common to cite that your
opinions are based on a review of certain documents, discus­
sions with the patient, and the conclusions are based on
training and experience. Depending on state law, there is
usually a customary fee for such a narrative, which should be
collected in advance of any dictation to the record. It is impor­
tant to cite when references are used, for it is not uncommon
to be given certain documents to help influence your opinion.
When all these documents are subsequently reviewed, opin­
ions may differ from the original narrative, which can now be
explained by specific lists of information reviewed.
Areas of the law
There are many areas of the law that have an impact on plastic
surgical practice. Most will include a claim of negligence,
which initiates your malpractice insurance. Other claims
either strengthen the malpractice claim or add additional
claims that are not covered by your malpractice insurance; all
are intended to add additional pressure to settling the suit.
Tort law: negligence, malpractice
Tort law is the basic area of the law covering negligence and
malpractice. There are four requirements of the negligence
action. The first area is a duty to provide care and acts in
question. The second is that duty is breached, usually in a
sub-standard way. The third requirement is that the breach is
directly responsible for whatever damages occur. This is
called proximate cause. And the fourth requirement is that
there are damages as the result of the prior three require­
ments. The proof and arguments surrounding these four
elements comprise a malpractice claim. Other legal interac­
tions will also involve your testimony establishing these four
elements. An example would be a dog bite resulting in a
lawsuit. You have surgically repaired the laceration and now
must testify that this injury is from the dog and the damages
that you describe are directly the result of the bite. While this
may appear ridiculous, as these questions are posed to you,
you can now see that the three elements of this tort case can
be established. The first element of that duty might be to
protect people from the dog.
Informed consent
The doctrine of informed consent is a necessary part of both
legal interactions and patient care. There are two standards

67
Fraud and abuse
should be addressed. If nothing is discussed or documented,
and the patient misses their major event, it could be judged
as your fault and you would be responsible for any financial
losses they incur. This is becoming more common, as patients
seek and demand quicker recoveries, adding procedures at
the last minute, all within a shorter and shorter timeframe.
Implied warranties could arise from time issues, financial
estimates and costs, future care and treatments, and issues
concerning results and expectations. Make sure the entire
office team discusses patient comments and interactions
because it is not uncommon to have a patient disclose varied
demands to a receptionist or coordinator and never mention
them to the surgeon. Include a paragraph in your informed
consent document as well as your financial agreement that no
warranties express or implied are present and that the patient
understands and agrees with this.
Product liability
Product liability issues cover the increasing number of prod­
ucts we distribute, utilize or prescribe. There are many areas
within product liability that would expose the practice. Those
arising from negligent use of a product may have claims
falling within their malpractice policy. Other misuse of a
product or altering a product by placing on your private label
may elicit additional claims not covered by your malpractice
policy. Any device, product, or prescription that is given to a
patient should include full instructions, risks, hazards, and
alternatives. A key factor in this area is that liability is created
in the foreseeable stream of commerce. That is when you give
a sample of a skincare product to your patient; it is foreseeable
that they might share that with family members and friends.
It therefore becomes important to provide good safety instruc­
tions as to its use, allergies if any, and concerns of treatment,
and document those in the record. When their friend uses the
product and has a reaction, you may be responsible, even
though you have never seen the friend as a patient. Adding
private labels to the product may hide important ingredients
and instructions. You should be careful to maintain such
important information. Altering the product, even as simply
as putting your name on it, may eliminate the manufacturer’s
responsibility to defend you for using it appropriately. Be
careful and investigate what are FDA approved uses for the
product and/or device. Be cautious when industry reps
suggest a different use without providing you with written
approval. A physician has the ability to prescribe off-label but
some precautions are necessary. The three necessary elements
for off-label use are: (1) that the product is approved by the
FDA for use; (2) that the proposed use is not experimental;
and (3) there should be written confirmation of the patient
accepting and understanding the off-label use.
Fraud and abuse
Fraud and abuse can definitely turn a winnable malpractice
case into one that has to settle or is lost. Fraud is defined as
the intent to deceive and abuse is defined as the intent to
confuse. There are multiple ways in which fraud and abuse
can be a part of a plastic surgery practice. Not only can fraud
and abuse have a very negative effect on the outcome of a
malpractice case, but in many states, a fraud conviction can
permission to show such information, a specific written
consent for commercial use must be signed by the patient. You
can help yourself and your practice by adopting HIPAA
rules,1 identifying a “red flag” office employee who can
safeguard patient identity, and being very diligent about
obtaining consent forms for treatment, release of information,
specific commercial use and photographic consents. Areas of
concern are thus social networks and blogs, such as Facebook
and Twitter. There is risk of a surgeon or practice describing
“a day in the life of a plastic surgeon” on a blog, but that day’s
patient may recognize him or herself, even though no name
is mentioned. There is metadata embedded within a photo­
graph that remains despite a file name change. It is important
to “scrub” or remove the metadata before posting or display­
ing any photograph even with specific written commercial
consent. The metadata may become visible when a mouse is
used to highlight a photograph even if named to prevent
disclosure. The HIPAA consent for treatment and documenta­
tion such as photography is inadequate when the photograph
is to be used to promote the surgeon’s website, even if for
educational value. The specific commercial consent must list
specific uses, length of time, where it is to be posted, and other
distributions. It is also a help to seek a Communication per­
mission from the patient outlining and documenting how
they may be contacted, either by cell phone, texting, regular
mail, at work or home or any type of social media.
Warranty law
Warranty law involves two specific types of warranty issues;
“express warranty” and “implied warranty”. You should
understand that warranty issues are not covered by your
malpractice policy. An express warranty utilizes a demonstra­
tive part of the record to create a guarantee towards a result.
This can be accomplished by including a photograph that the
patient brings of a result they seek, or it may change created
results that are made a permanent part of the business record.
It is well accepted among physicians that there are no war­
ranties or guarantees towards a result, since healing can be so
specific and usually out of the physician’s control. While the
visual aids are important in educating the patient about pro­
cedures and expectations, the practice should be very careful
not to establish a guarantee of a certain result. Patients seem­
ingly have unrealistic expectations, as the media and other
factors portray certain social appearances. Utilize all educa­
tional tools including imaging to help the patient understand
the procedure and the results but make sure you have both a
disclaimer and documented discussions concerning realistic
expectations.
The implied warranty can be more difficult. This is not
based on something added to the chart that is tangible but
rather an understanding that the patient presents to you that
you must consider and address. Examples might be the fact
that two weeks after a major surgery, the patient is expecting
to travel to a family or business retreat. There is a possibility
that the patient reasonably may be able to attend such a func­
tion, but are you willing to guarantee they will heal appropri­
ately to do so? This becomes the main issue of these implied
warranties. The patient discloses a requirement that they
present. You should be careful to disclose and document the
many reasons that might interfere with their requirement.
Possibly changing the date of surgery or other considerations

68
CHAPTER 6 • Medico-legal issues in plastic surgery
procedures, possibly suggesting the total operative time was
for the hand surgery alone.
Fraudulent concealment is yet another type of fraud that
can plague the practice. If false or misleading information is
given to a patient that they have been relying on, a fraudulent
concealment claim may be generated. The significance of this
is that it still is fraud, there is no malpractice insurance cover­
age, and it tolls, or extends the statute of limitations. That
means if there is a 2-year statute of limitations after which an
allegation claim is not valid, a fraudulent concealment issue
can remove the statute’s effect and render the claim still valid.
An example where this may occur is in a lesion that is excised
on the back with frozen sections showing removal of a squa­
mous cell cancer with margins free of disease. The permanent
section, however, and the final pathology report show tumor
at the superior margin. This information is not disclosed to
the patient who develops a recurrence; files a lawsuit 1 year
after the statute of limitations would have prohibited such a
lawsuit. A fraudulent concealment claim allows the lawsuit to
proceed.
“Qui tam”, part of the False Claims Act,2 has the federal
government rewarding fraud whistleblowers. Basically, a
disgruntled employee files a false claim lawsuit against you,
the employer, citing fraudulent claims, and the US govern­
ment joins the lawsuit, allowing the whistleblower to collect
a percentage of any judgment or settlement. This emphasizes
the need for appropriate, ethical billing and coding, as well as
eliminating disgruntled employees from the workplace.
Contract law
Contract law should have a limited role in plastic surgical
practice. It is suggested to have a work employment contract
with independent contractors, physicians in the practice, and
aestheticians. Such an agreement would cover work-related
requirements, ethical and legal standards, confidential and
HIPAA requirements and other safeguards to the workplace.
It is not uncommon for an aesthetician, employed by the
practice, to quit and take all of the confidential patient infor­
mation to their next place of employment. This is a direct
HIPAA violation and there is a duty to retrieve and protect
such information. Having a protective clause in your employ­
ment agreement prohibiting such an act is a further safeguard.
Some states, such as California and Colorado, allow arbitra­
tion clauses as part of their state-wide tort reform. It can be
attractive to establish such an arbitration required agreement
in advance of surgery but it would not be legal to remove the
patient’s right to bring suit. One can argue further that the
more a contract is established with a patient, the more likely
a breach of the contract can be claimed when the results do
not equal the patient’s expectation. Contract law would be
more of a problem in descending results and care than tort or
negligence law. The patient merely has to prove that the
contract was breached and their expected results failed, to
collect money, whereas in a negligence action the physician
must be proven to have acted negligently, which is usually
more difficult to establish. A breach of contract merely requires
that a contract be established and a party failed to fulfill their
end of the agreement. Damages are paid to fulfill the contract.
A negligence claim, however, requires a party to be negligent
as to a duty of care, and damages are paid to compensate for
both jeopardize your medical license and involve criminal
activity. One way of avoiding the perception of fraud is to
assure your medical billing and coding conforms to your
operative record and treatment notes. It is generally under­
stood that the codes used for billing can be changed as an
ongoing process. You must be consistent when adjusting the
billing codes to reflect ethically on the procedures and treat­
ments performed. Another area of exposure to fraud is the
medical record. Altering a medical record can also expose you
to both civil and criminal penalties. There are many ways to
disclose an altered record that you should be aware of.
One technique involves an ESDA test, which measures
pressure indentations on a page. An ESDA (electrostatic detec­
tion apparatus) is a piece of equipment commonly used in
questioned document examination, to reveal indented impres­
sions on paper, which may otherwise go unnoticed. It is a
nondestructive technique (will not damage the evidence in
question), thus allowing further tests to be carried out. It is a
sensitive technique, and has been known to detect the pres­
ence of fresh fingerprints. When writing is fashioned on a
sheet of paper resting upon other pages, the impressions
produced are indented onto those below. It is these indenta­
tions which are detected using ESDA, thus allowing a match
of the original document to its source (such as a ransom note,
or a threat to extort) to the offender’s notepad.
Where two or more handwriting styles can be found mixed
into a single document, and features of one handwriting style
depart from the features of the other, ESDA can help reveal
the differences in pressures employed between the individu­
als responsible for the writing samples, otherwise unified on
a single exemplar. An indentation on the page below can be
evaluated to show corrections, additions, and other informa­
tion about writings. A hospital chart has the most recent
chronology on the top with past recordings on the bottom.
When the patient is discharged, the chronology is reversed
with the earlier dates on top and later dates on the bottom.
Consequently, if there is a pressure indentation on a later
date’s page, that entry was made after the patient was dis­
charged, which is altering a record.
Another method of documenting record alteration is analy­
sis of the inks used. Each ink is dated and it is possible to
confirm suspicions by testing the date of a questionable record
entry. Records are changed appropriately based on misstate­
ments and incorrect entries. The proper method of correcting
a medical record is to draw a thin line through the misstate­
ment allowing readability in addition to making an entry
contemporaneous to the correction date and time in the
record. Both entries should be initialed and date and time
confirmed.
A further example of potential concern occurs when mul­
tiple procedures are performed necessitating two operative
reports. The patient has carpal tunnel syndrome and is seeking
liposuction. Her insurance through her business is self-insured
and the employee health representative is a gossip, so she asks
you to not disclose the liposuction to her company. The
appropriate course would be to dictate two operative notes
and make reference about each within each. The hand surgery
operative note would make reference to an additional surgery
to be dictated separately. The liposuction operative note
would confirm prior hand surgery occurred and this proce­
dure followed. A question of fraud or abuse that is deceiving
or confusing would be to have no reference of both

69
Internet and “blog” defamation law
in the practice to understand and comply with these rules. It
is unwise to ask an employee to care for a patient when it
violates state rules. An example would be an aesthetician who
was asked to inject Botox® when the state prohibits anyone
but a physician, nurse practitioner or physician assistant to
perform such an injection. Another example is to have your
laser technician treat patients with you, the physician, out of
the office and the state requires direct supervision of such
treatments by a physician. If there is a bad outcome of such
treatment, or anything that would trigger an investigation; it
severely damages any defense raised and could void malprac­
tice liability coverage. The practice must be vigilant in keeping
up with the each state board rule and regulation, and deci­
sions that affect a medical practice, nursing practice and
others who participate in a plastic surgical endeavor.
Agency law
Agency law encompasses those in the workplace and their
interactions. It is a doctrine that the employer is responsible
for negligent acts of the employee during the scope of employ­
ment or in furtherance of the business. Any negligent acts by
an employee are attributable to the employer. It therefore
becomes important for the employer to outline what is accept­
able and unacceptable behavior, usually in an “office policy
manual”. Supervision becomes important, as claiming that
one was unaware of risky or negligent behavior is no excuse
and will not defer blame. You should have been aware of risky
or negligent activity. However, violating the office policy
manual that clearly defines what should not occur may help
protect the practice against a liability claim. The practice
should make attempts to avoid harassment in the workplace
while developing a good team for communication with
patients. Problem employees should be addressed promptly
following the office policy manual as to counseling, disciplin­
ary action, and termination. There should be documentation
as to how these issues are addressed so if an ex-employee
challenges their dismissal, the practice can support the
decision.
There are many employee issues such as embezzlement,
disruptive employees, employees who “steal” patient infor­
mation, and have disagreements about hours, vacation and
daily routines. All should be covered in the manual. Embezzle­
ment can be potentially avoided by having a dual system of
checks, say accounts payable and receivables matched against
bank statements. One employee responsible for both sides
may be a formula for theft. Develop written policy for hours,
telephone, smoking, vacation days, and patient interactions
that everyone agrees with, and sign a kept copy. Have a
confidentiality clause that forbids theft of patient information
describing HIPAA violations and the requirement of the
practice to pursue those who violate this clause. A common
example is the aesthetician employee who leaves for another
job and takes all of your patient data to the next job. HIPAA
requires you to protect such data and make attempts to
retrieve it.
Internet and “blog” defamation law
The internet has dramatically influenced the practice of
plastic surgery. Patients e-mail us from multiple states and
seek information about care. It seems that patients share their
the negligent act. Develop an office policy manual outlining
appropriate and expected care, as well as restricted and pro­
hibited acts. Utilize an updated employment agreement for
staff similarly outlining required and prohibited behavior.
We are observing an increase in “contract” personnel, often
in the form of aestheticians, or operating facility staff, etc. The
practice should be careful here in establishing guidelines for
such individuals. This should be covered in an office policy
manual. Contract personnel are not employees, and should
have their own liability, not falling under agency law. This
means you cannot totally manage their daily work, or cover
them with insurance like the other employees. The issue of
“control” over their work product is an important factor in
labeling them as contract personnel or an employee; not the
language used in their agreement. You should continually
check on their licenses, malpractice history, and quality. You
can provide them with the tools to perform their work, but
not control their work such as you would with an employee.
The issue is whether you will be responsible for their alleged
negligence should a claim be made. The independent contrac­
tor is liable for their own negligence, while the employee
through Agency law is your responsibility.
Regulatory issues within the law
There are many regulatory agencies overseeing a plastic surgi­
cal practice. The HIPAA is established to protect patient
privacy and medical information. The patient should sign an
acknowledgment of their privacy protection, and this is kept
in the patient’s file. There are obligations to safeguard against
identity theft, known as “red flag rules”.3 The practice must
identify an individual to record each patient’s identity and
inspect for procedures, billing, and insurance correspondence,
to assure appropriateness throughout. This can include pos­
sibly copying the patient’s ID, such as a driver’s license or
passport, including a photograph of the patient, and checking
the above documents so they match the practice’s care and
treatment.
The Occupational Safety and Health Administration
(OSHA)4 covers office supplies and equipment assuring safety
in the workplace. All supplies should be labeled with appro­
priate precautions marked, as well as a log of emergency
treatment, should an accident occur. The FDA controls manu­
facturers of devices and products and although does not
directly oversee physicians, there are requirements necessary
for off-label use. Off-label use involves the nonexperimental
use of an approved FDA device or product in a nonapproved
fashion. Such use should have a specific consent documenting
off-label usage and acknowledging patient acceptance. The
practice should be very careful to only purchase FDA-
approved supplies and avoid the temptation from frequent
internet and mail solicitation for supplies that are “just like”
those approved. Such a purchase would be illegal and could
make the purchaser and practice subject to civil and criminal
charges. State medical boards as well as state nursing and
other regulatory agencies outline appropriate care in the
office. It would behoove the practice to inquire about new
standards and guidelines that apply. Ignorance is no excuse
for inappropriate behavior. State board actions describe who
can do what in an office environment and with what degree
of supervision. It is very important for all staff and physicians

70
CHAPTER 6 • Medico-legal issues in plastic surgery
remove the blog. These actions by disgruntled patients have
damaged many practices and threatened more. Attempts are
being made to better control blogging sources in an effort to
make this more fair and balanced.
Basic actions of a malpractice lawsuit
(a guide)
There are many stages of a malpractice lawsuit. They include
notice, discovery, pretrial motions, trial, and aftermath.
Notice of the intent to file a lawsuit is controlled by each state
with a required timely response by the physician or practice.
Notice is usually provided certified for by a delivery service
and must be taken seriously. As soon as notice is received,
secure the medical records, and notify your malpractice
carrier. Fight the urge to add to the medical record or alter it
in any way. Obtain copies of the medical record from hospital
facilities as well as your own office record. It may be wise at
this point in time to ask employees as well as yourself to
write a recollection of the patient’s care and treatment with
key words used prior to such writing, on advice of counsel
and on anticipation of litigation. A life of a lawsuit may be
over five years, and remembrances get lost over time as well
as employees leaving. It is therefore suggested that, “on
advice of counsel”, each employee and physician in contact
with the plaintiff write what they remember and keep these
writings separate from the medical record. Keep these writ­
ings privileged and available only as an attorney–client work
product, which the other side should not obtain. Keep these
recollections separate from the medical record and under
lock and key. There will be requests for medical records from
the plaintiff and your malpractice carrier. You should have
meetings with your carrier’s agent and the assigned law firm.
Usually notice is not the actual lawsuit but the intent to file a
lawsuit should a settlement not be reached. Your carrier,
attorney and you will discuss the case in depth evaluating
the facts, standards of care, and defensibility. Once a lawsuit
is filed, your team will develop an answer within the timed
requirement and the process begins. Follow your hospital
and facility by-laws, which might require notification of such
a lawsuit.
The next stage is discovery. Discovery includes responding
to written questions called interrogatories, and depositions to
record testimony for future use. This process may take a
number of years. You should remember to never respond to
any such request without your attorney’s input. You will have
noticed your deposition well in advance and utilize the time
to prepare at length with your attorney. All parts of discovery,
such as depositions, require advance written notice of time
and place. This allows one to prepare, collect information
from the record, and seek consultation with legal counsel
before actually providing the deposition. I would recommend
you prepare with a senior attorney rather than the most junior
associate. While you are quite comfortable in the operating
room, the attorney is more comfortable taking your deposi­
tion. You must prepare by expecting certain questions, dis­
closing all concerns to your attorney, and understanding the
process of the deposition. Once all the facts are gathered, a
trial date is scheduled – make sure to block your calendar and
devote the appropriate amounts of time for preparation. The
pretrial stage includes demands from each side for exclusions,
experiences on many of the social networks. Generally, the
internet can bring us additional exposure and patients, while
adding significant risk and potential problems. Some basic
guidelines concerning e-mails are not to answer out-of-state
inquiries with any specificity that the prospective patient can
rely on. Failure to follow this guideline may expose you to
practicing in the state in which you have no medical license
– a crime. This only applies to prospective patients with
whom you have not yet entered into a doctor–patient rela­
tionship. The practice should develop generic answers con­
cerning basic information to respond to the out-of-state
resident. It is usually recommended to include a disclaimer,
e.g., if your symptoms and condition worsen you should seek
help immediately in your community. The ongoing corre­
spondence between the practice and the patient should be
copied and recorded in the patient’s chart. Telephone texting
should have a similar documentation in the patient’s file.
Much of ongoing communication today involves internet
messaging and it behooves the practice to establish policies
which make such communication a necessary part of the
medical record.
Many practices wish to enter the social networking com­
munity such as on Facebook or Twitter, establishing blogs and
plastic surgery updates. One has to be very careful not to
violate patient confidentiality by disclosing private informa­
tion about procedures. One has to take care and not even
mention what procedure you are doing on a specific day, as
friends of the patient who might believe that day is reserved
for their friend are now aware of the specifics about the pro­
cedure, which is a violation. One way around such exposure
is to utilize generic procedures that are not specifically tied to
a given day and include patient safety issues, general patient
instructions, and current trends of plastic surgery. The practice
must maintain a high level of professionalism complying with
the HIPAA and other privacy issues. The use of photographs
for commercial education and internet website usage require
a specific written consent acknowledging their use. This is
separate from the general photography consent considered as
a part of diagnosis and treatment. The same considerations
are given for office photographs, books, and references dis­
played to other patients.
A recent troubling trend is blogging by patients against the
practice. A patient may have a perceived problem and begins
to write on a website or a blogging page their interpretation
of the negative. This is clearly one-sided and may in fact not
be accurate. Despite this, the practice cannot respond, due to
the HIPAA, without a specific written authorization. This
one-sided attack poses great concern. There are attempts to
control patients’ speech through copyright law, but many
believe this to be either unethical or restrictive. It may be
suggested to develop a non-patient-specific practice blog
outlining complications, noncompliance, and high risk proce­
dures, as a balance to these attacks. The first inclination would
be to attack the blogger legally, however First Amendment
speech permits such opinions. The attacker who creates a fake
website mimicking the practice is confusing and misrepre­
senting to the public, and may be subject to a lawsuit if you
can identify and find them. Another suggestion is to utilize
the internet search engines to place their blogging page on the
second or third internet page, thereby reducing visibility. This
will often lead to “games” where each attempts to manipulate
the other, resulting in an extortion demand for money to

71
Liability carrier’s issues
you see prospective patients at least twice preoperatively
allowing time for questions and procedure refinement. Include
financial agreement discussions about costs of the proposed
procedure as well as future costs, especially if a complication
occurs. Develop a team to both address the patient’s needs as
well as discuss appropriate procedures and treatment plan.
Recognize today’s social pressures and media influences to
present options to the patient that are realistic for the physi­
cian to achieve their goals. Try and avoid gimmicks and
competing with unrealistic choices to keep the patient in your
practice.
Managed care liabilities
The distance between aesthetic surgery and managed care/
reconstructive surgery is narrowing. Patients have as many
demands and unrealistic expectations for reconstructive
surgery as they may exhibit in aesthetic surgery. The practice
should present realistic options and procedures to the patient
and after a clear understanding and acceptance, proceed with
treatment. Additional concerns may arise with managed care
coverage, and these should be addressed with the patient
with good documentation. Your authorization letter should
be honest, complete, and represent the facts and why treat­
ment is medically necessary and appropriate. As you know,
it is not uncommon to receive a denial, but remain a patient
advocate and appeal as appropriate and necessary. The prac­
tice should be careful in not discussing fees with competitors,
as this could violate antitrust laws. If you provide service
through an emergency room, and not on the patient’s
managed-care panel, attempt to see the patient postopera­
tively without charge and document their satisfactory
progress.
The Affordable Care Act creates liability on the physician
even though a PA or nurse practitioner may actually see the
patient. If the expected volume of patients become involved
in care, physician interaction for all patients becomes impos­
sible. There will be delays in treatment as well as rationing of
care. It behooves the physician to establish criteria for treat­
ment and a direct supervision method to assure appropriate
care for all seen under the physician’s umbrella.5–7
Liability carrier’s issues
The choice of carrier providing your malpractice insurance is
a critical one. Inquire as to their financial stability, track record,
coverage inclusions, claims made or occurrence type, oppor­
tunity for purchase of a tail, and contractual decisions about
settling claims. There is an increase in state board complaints
and ask whether representation is included in their coverage.
Check on which law firms represent physicians through the
carrier and how responsive they are to the physician. It is not
only the premium that should affect your choice. Many physi­
cians have paid a very low premium only to subsequently
find out the company is bankrupt and they have no coverage
at all. There are carriers common to plastic surgery that are
active within our societies and understand the nuances of a
plastic surgical practice. Determine your limits of coverage
based on your practice, hospital privilege, and risks and
exposures. The level should be appropriate to maintain hos­
pital and facility privileges, yet not excessive, helping to make
expert testimony, and other concerns about your case. Fre­
quently, arbitration or mediation is recommended by the
court. A failure to reach settlement brings the trial date to
schedule. The trial itself may take 1–2 weeks, depending on
the complexity of the case and the court’s schedule. You
should plan on being there every day, following the advice of
your counsel, being extremely respectful of the process and
visibly concerned and gracious. The defense has two experts,
while usually the plaintiff only one. You are your case’s best
expert and an additional expert is hired. Work with the expert
and your attorney to win your case. It may be wise to travel
with your attorney when taking the deposition of the plain­
tiff’s expert as you may provide valuable on-site information
to assist in their deposition. You will not be reimbursed for
such travel, but the value to your case may far exceed your
expenses. The last stage may involve appeals and other judi­
cial and legal maneuvering, pending the outcome of the trial.
Aesthetic practice liabilities
The aesthetic plastic surgery practice has specific risks inher­
ent to this area. Patient expectations are paramount to achiev­
ing desired goals and limiting risk. A disturbing trend is the
lack of patient accountability combined with an unrealistic set
of goals. It appears that any inherent risk or complication
generates a legal concern even if fully disclosed in an informed
consent document. More than ever, patient selection and
appropriateness of procedure is important. Patients often
demand certain procedures and the practice should be careful
to assure the proposed procedure is an appropriate fit for this
specific patient. Many believe it safer to create a more specific
informed consent document listing the additional risks of
such patient demands. The problem with this is that you may
create additional risks by outlining such in a consent docu­
ment. The ultimate responsibility of patient acceptance is
yours and no document will protect you against an inappro­
priate decision. Smoking continues to be a major source of
liability, as it affects healing as well as scarring and overall
recovery. Adding additional risks to the consent is a good
example of not avoiding liability where a better choice would
have been not to accept the patient. Trends toward more mini
procedures, while desirable for the patient, may not achieve
the desired goals. Breast surgery continues to be the lead of
malpractice claims, with augment mastopexy the majority.
Any delay in healing, poor scar, or shape often leads to a
lawsuit. Other trends concern where the surgery occurs, as
questions arise after lengthy surgery in an outpatient setting.
The balance between appropriate procedures, facility and
anesthesia versus cost continues to be an issue.
Cosmetic medicine has assumed a lead in number of pro­
cedures performed and must follow general guidelines for
risk prevention. Each skincare treatment, toxin injection, and
filler injection should have a consent document. Additional
concerns about who provides the treatment should follow
state law, be it the medical board of the state, nursing board
of the state, or skincare aesthetician governing body of the
state in question. Establish patient care guidelines and follow
them throughout the practice. An example might be: a patient
for IPL treatment who, despite being told not to get a suntan,
comes in for a treatment with a tan. It is wise not to treat the
patient, despite their anger or demands. It is suggested that

72
CHAPTER 6 • Medico-legal issues in plastic surgery
a restriction for the practice of medicine for a period of
5 years in the entire city will probably not be enforced.
However, a restriction for the practice of plastic surgery
for a period of 1 year within 5 miles of every office
location currently used probably will be enforceable.
Another option is to consider a “liquidated damages
clause”. This acknowledges the difficulty in enforcing
such restrictive covenants, and in advance, arrives at a
money settlement (e.g., $150 000) that the leaving doctor
must pay the other doctor for breaching restrictive
covenants. This amount may be withdrawn from
accounts receivables due to the leaving doctor or other
arrangements that are enforceable.
There are many more considerations necessary for a suc­
cessful association, despite the legal structure. The most
important is perceived fairness and ongoing attempts to keep
it positive, efficient, and responsive to the many changes and
challenges affecting the plastic surgery practice.
Patient selection
Patient selection has become the most important part of risk
protection as well as practice building. There is a disturbing
trend of less accountability in the patient and an approaching
“must be perfect” expectation for the practice. Lawsuits have
been filed by patients who develop a known inherent risk of
a procedure, despite having good documentation about such
risks in advance. Lawsuits have been filed even with poor
patient compliance, even when discussed in advance of how
important this is. It approaches a mindset that any inherent
risk or complication must have been the result of “something
done wrong”.
The key to limiting this is to choose patients you feel you
can trust and those for whom you can realistically reach
their expectations. It is wise to see the patient more than
once pre-treatment to assess their goals and expectations, as
well as how they interact with you and your staff. In tough
economic times, it is difficult to say “no” to a patient, but
“no” is much preferable to defending a malpractice lawsuit.
Be realistic in approaching your choices of procedures.
Patients are becoming more specific-procedure driven, rather
than issue driven. They might come in asking for a facelift,
when in fact other choices might be more beneficial and
appropriate. We should educate them and understand we are
responsible for the choices made, not the patient. We are the
experienced physicians and our role is to protect and guide
the patient, sometimes protecting them from themselves. It
is not appropriate to grant the patient’s desires unless they
are appropriate and achievable. There is a difficult defense in
a malpractice suit when the defendant physician states “the
patient wanted this procedure and signed all the informed
consent documents indicating greater risk”. The physician
has the task of approving procedures, not the patient. The
patient cannot appropriately consent to an inappropriate
procedure. The surgeon should have either rejected accept­
ing the patient or suggested an appropriate procedure.
There is distinct added liability from not following this
principle.
Dr Mark Gorney developed a “GorneyGram” that helps
physicians assess realistic goals of the patient (Fig. 6.1). It
balances the deformity present against the effect such a
you a target. Evaluate companies that encourage discussion
about problem patients while not considering each inquiry a
claim. Look at their rating and past record in a plastic surgery
arena.
Legal issues in physician partnerships
A higher percentage of physicians are associating with part­
ners than in the past. It becomes important to understand the
legal implications of such arrangements. There are many
types of associations from full partnerships, office-sharing
arrangements, limited liability partnerships, single specialty
groups, and multi-specialty groups. One considering such an
association should seek input from their accountant, attorney,
estate financial planner, family, and compliance with their
business plan. Spend considerable time with the individual
you seek to join or associate with. It is amazing how often
what started as a great idea of like minds ends up with exas­
peration in being so different in goals and style. Make sure
you complement each other, and can retain some of your
autonomy and individualism, important to a plastic surgery
mindset.
Whatever format you choose, establish a communication
mechanism, as well as a conflict resolution format. The best
of intentions can rapidly go downhill without continuing to
“make it work”. Have legal counsel work with your business
plan to make it equitable and yet protective to both/all parties.
All aspects of the arrangement must be considered, especially
financial, and termination issues. The agreement is a binding
contract and must reflect all considerations agreed upon.
There should be no verbal or handshake addendums that are
not included within the pages of the agreement.
Issues to consider and resolve are:
1. Ownership – office, equipment, other investments, and
the right to make decisions about new and past
expenditures
2. Duration of the agreement, including renewals,
termination, and adjustments
3. Duties and expectations of each party should be
carefully defined and described
4. Financial allocation of expenses – fixed (rent, employees,
leases, personal expenses, e.g., pager, etc.), variables
based on collections (medical supplies, office supplies,
etc.)
5. Ethics – defining standards (ASPS, ACS, state board,
federal), malpractice requirements
6. Termination process – who gets what, staff issues, costs
involved, e.g., to copy records, etc.
7. Hold harmless clause – adding staff and physicians’
decisions, management of office
8. Accounts receivables (always difficult) – possibly a trust
established by senior associate keeping funds collected
by junior associate, but in name of junior associate, only
released when agreement and liabilities are resolved
9. Financial considerations – bonuses, salary, advances, etc.
10. Confidentiality clause
11. Marketing; advertising
12. Ownership of telephone number, name, etc.
13. Restrictive covenants – can and will be enforced as long
as “reasonable” as to time, description, and distance. So,

73
Summary
default smart text phrases but, if incorrect, this sets up the
physician for liability. The physician exam with “No masses
seen” as a default text must reflect the reality that no masses
were seen. It is suggested that the smart texts are reviewed
for accuracy and inclusion. Once signed, you verify the cor­
rectness of the medical record. If such entry is incorrect or
false, your credibility in the courtroom is questionable. The
third area of EHR concern relates to privacy issues. An aes­
thetic patient seeks a breast augmentation and liposuction.
She demands that this surgery remain private and is not to be
shared with anyone. No insurance is involved and therefore
no fraud issues arise. However, in a health system all the data
from her surgery is in the EHR for the next physician to
observe. I am not aware of a mechanism to restrict such data,
preventing viewing by future physicians unless the patient
approves or it is necessary for care. I would explain this to the
patient. Even though they seek confidentiality, their EHR
record will include all surgeries they have experienced.
HIPAA should prevent subsequent healthcare providers from
disseminating such information, but patients have become
angry at their plastic surgeon when a family practice physi­
cian discusses their breast augmentation and the patient
believes you were told to keep it private.
Summary
There are many legal interactions and risks within a plastic
surgical practice. One should be aware of these risks and
develop standards of protecting the patient, practice, and
physician. I would suggest attempting to keep up with
the changing medico-legal environment by attending risk
courses; explore state medical board rule changes, and
the plastic surgery societies’ panels. Establish relationships
within the legal community as your practice grows. This will
become a useful resource for questions that arise and have a
positive impact on the medical malpractice arena. Under­
standing all of the above is important, but the most impor­
tant risk protection is appropriate patient selection. Choose
patients you like and feel you can trust, and develop a rela­
tionship. Match the chosen procedure with their expectations
and follow them as you would want to be seen if you were
the patient. Develop a team that reflects your attitude and
caring for the patient.
References
1. The Health Insurance Portability and Accountability Act (HIPAA) of
1996 (Public Law 104–191). Privacy and Security Rules.
2. The Federal False Claims Act (31 USC ss. 3729–3733). False Claims.
3. The Fair and Accurate Credit Transactions Act of 2003. Identity Theft
Red Flags and Address Discrepancies. Federal Register. 72:217 (9
November 2007) p. 63718.
4. Occupational Safety and Health Administration. Available at: >.
5. Obamacare, Top 10 Pros and Cons. Available at: <
reform.procon.org/view.resource.php?resourceID=003725>;
2015.
6. Physician says Affordable Care Act an ‘experiment’ that will fail. Available
at: <
affordable-care-act-an-experiment-that-will-fail>; 2013.
7. Obamacare Pros and Con. Online article. useconomy.about.com/od/healthcarereform/a/Obamacare-Pros-
And-Cons.htm>; 2016.
deformity has on the patient. For example, Quasimodo, the
hunchback of Notre Dame, seeks contour corrective surgery.
He states anything you can do to improve things would be
great. Quasimodo would be on the bottom right of the Gor­
neyGram; a good place to be. Another patient with a minimal
small 1 cm scar on her lower cheek from chickenpox cannot
leave the house without covering it to extreme. This patient
is in the upper left area of the GorneyGram; a most danger­
ous place. Likely, nothing you can do will help the patient to
her acceptable level. There should be an assessment of all
patients to see where they lie on this scale. Some areas will
change over time, but it is amazing how accurate this is
overall in helping to define which patients are better candi­
dates for your care.
Electronic medical records
The Affordable Care Act has increased the requirements to
utilize electronic health records (EHR), but with an increase
in patient complaints and claims. The necessity of document­
ing on a computer or tablet can remove the face-to-face
interpersonal contact with the patient. It has been well
accepted that patients are less likely to bring a medical negli­
gence claim against a physician they like. Often the doctor’s
mind is focused on a computer and not on the patient, becom­
ing an obstacle in the doctor–patient relationship. It is
suggested that a routine is developed in which a direct inter­
personal discussion with the patient begins, and only after a
relationship is established will after an apology in needing to
document this examination and treatment the doctor focus on
appropriate documentation. This new paradigm is a learned
behavior and some practice may help achieve the proper
balance between correct documentation and a personal visit.
The second area of risk associated with EHR is the “smart
text” developed for each specialty to facilitate data entry and
speed up the required time. The default data developed by
the programmer, usually along with the physician, must be
checked to assure it is correct. It might be easier to utilize
Fig. 6.1  Dr. Mark Gorney developed a “GorneyGram” that helps physicians assess
realistic goals of the patient.
Deformity
Patient selection guide
Concern
1
2
3
4
5
2
1
3
4
5

74
CHAPTER 6 • Medico-legal issues in plastic surgery
Nora PF, ed. Professional Liability/Risk Management: A Manual for
Surgeons. 2nd ed. Chicago: The Professional Liability Committee,
American College of Surgeons; 1997. An update on subjects in the area
of professional liability and risk management that have changed since the
1st edition was published in 1991.
Further reading
Federal Food, Drug, and Cosmetic Act (FD&C Act). Medical device
safety business associate contracts. Sample business associate
contract provisions. FR 67 No.157; 2002:53182, 53264.
Gorney M. Ten years’ experience in aesthetic surgery malpractice
claims. Aesthet Surg J 2001;21:569–571.

7 
Digital imaging in plastic surgery
Daniel Z. Liu and Brian M. Kinney
SYNOPSIS
■ Photography is not only useful, documentary, collaborative, didactic,
medical–legal, a research tool and even promotional – it is standard of
care and a sine qua non for proper practice in plastic surgery.
■ Our specialty is highly visual and relies on accurate representation of
form, as well as function, to diagnose, plan, treat, evaluate, and track
patient surgical outcomes.
■ The photographic record contains much more information than can
easily be documented in words, including color, tone, texture, shape,
vascularity, bulk, spatial relationships of anatomic structures, global
aesthetics, aging, and historical changes, to name only a few.
■ The value of images increases with time.
■ Technological advances in videography and three-dimensional surface
imaging in plastic surgery may improve communication, education,
and patient satisfaction.
Purpose
The first principle of photography as a medical record is to
document the pre- and postoperative condition of the patient,
serving as an accompaniment and function analogous to
radiography. Preoperatively, the record is a guide in evaluat­
ing the patient’s condition, highlighting relationships of the
anatomy, and demonstrating aspects of physiologic function
for tissues like the nose, eyes, mouth, and hand. Postopera­
tively, images record changes for patient teaching, self-
evaluation for retrospective review, and assessment of results
vis-à-vis planned outcome. Intraoperative imaging may
feature key aspects of the surgical procedure.
Much of plastic surgery rests in an unusual setting in
medicine. The core and history is reconstructive in nature,
largely born from efforts to rebuild injuries sustained by First
World War soldiers. Whether reconstructive or aesthetic, its
essence is to restore form and function, and today, a great
portion is neither urgent nor critical to immediate health.
Instead, much is elective and focused on quality of life,
especially in the aesthetic arena. Reviewing photographs with
a patient may transform the preoperative planning from an
interaction tilted one way from the doctor to the patient.
Instead, the effort may be collaborative and consultative, an
interaction between the doctor and the patient.1,2 Various
scenarios can be examined and evaluated with digital imaging,
modeling and morphing. Care must be taken when showing
potential postoperative results, to avoid the implication of an
implied or guaranteed result.3 One popular software program
(Mirror Image)4 contains an important default disclaimer,
“Simulation only: Actual results may differ.”
The didactic nature of medical photography cannot be
underestimated. Decades ago, sketches were used, followed
by black and white photography, color transparencies and
film, with the modern progression to digital images in the last
20 years. For all practical purposes, analog photography is a
niche market, and digital imaging reigns supreme. Between
the consultation and the operative procedure, planning
requires good recall and representation of the anatomy. The
images serve to refresh the memory of the surgeon. In addi­
tion, it is critical for patients to understand excesses or defi­
ciencies of tissues, issues of symmetry.3 Features of their
anatomy may facilitate or hinder surgical planning, influence
choices in surgical approach, affect risks of complications,
compromise or augment patient satisfaction. Patient teaching
requires proper photographic representation of the preopera­
tive condition and explanation of the changes achieved with
surgical intervention. The evolution of a surgical practice can
be tracked most easily over a period of years through system­
atic inspection of imaging of the patients’ condition through
the course of their diseases or conditions. A particularly
common phenomenon is for a patient to not recall how they
looked before surgery when critically viewing the postopera­
tive result. Occasionally in reconstructive procedures and
more often in aesthetic ones, the patient’s psychological “set
point” is re-established at their current condition, and the
desire for further enhancement leaves them with falsely ele­
vated expectations. Photos are indispensable in this setting
and may provide reassurance that goals have been reached.
  Access video lecture content for this chapter online at expertconsult.com

76
CHAPTER 7 • Digital imaging in plastic surgery
increasing use of imaging improves learning and documenta­
tion. In coming years, widespread use of artificial intelligence
for image processing will likely allow for digital data mining
of the image content itself. This would be a major advance­
ment beyond assigning database attributes to digital files like
age, preoperative and postoperative photograph dates, type
of procedure, etc. Instead, we may begin to see digital refer­
ence to quality of outcomes, conditions of anatomy on vali­
dated grading scales, etc. Even now, consumer digital cameras
and photography software have “face finders,” automated
red-eye reduction and similar tools. Professional systems have
capabilities like automatic pore evaluation on the skin and cell
counters for microscopic work. One could imagine many
future potential applications like automatic color detection,
evaluation of cutaneous vascularity, flap perfusion and others.
Since the mass “migration” to the internet by the general
population, the public has turned online to research plastic
surgery, compare results, investigate complications, nurture
special interest groups and procedures, and engage in promo­
tion and marketing. There are many egregious examples of
excess, manipulation and deception; however, there are even
more beneficial opportunities for patient education, practice
marketing, advocacy and public health outreach. In addition,
surgeons often disregard photographic documentation stan­
dards of care.8
Standards in capturing images
Little has changed for the framing and composition of images
since Morello et al.9 and Zarem,10 and many before them speci­
fied these aspects of photographic standards in plastic surgery.
However, many other factors have evolved in the transition
to the digital world.11 Key principles must be followed.12
Consistency in results is affected by numerous factors.7,9,10,12
Facial photographs are taken at the 35 mm camera 100 mm
lens digital equivalent, while body images are taken at the
50 mm lens equivalent.13 Shadows should be avoided. Colors
must be natural. Lighting should be unobtrusive and consis­
tent. Standards must be obeyed.14,15
Digital image characteristics
Many variables affect images, and many are in the control of
the plastic surgeon. Parker et al.7 have documented four basic
ways in which inconsistency is introduced into photography:
(1) photographer-based; (2) publisher-based; (3) combined;
and (4) patient-based. Category 1 in their scheme includes
view (composition), background and zoom, which are gener­
ally consistent among journals. Publisher-based criteria, size
and image labeling are less problematic. Combined criteria,
color, brightness, contrast, and resolution vary in published
journals. Category 4 criteria: clothing, accessory apparel,
make-up, facial expression, and hairstyle, are designated as
patient-based, but are substantially under the control of the
photographer. A dark-colored “collar” drape can be used over
the shoulders for facial photographs. Accessory apparel
should be removed, as make-up, false eyelashes, and similar
accoutrements of fashion may interfere. Hairstyle can be miti­
gated by using standardized hairbands or ties. Patients can be
coached to maintain neutral facial expression.
Galdino categorizes factors into direct and indirect.11,12 Direct
variables include lens, viewfinder, digital chip, resolution,
Maintaining proper images and systematically evaluating
them postoperatively can only improve awareness of surgical
choices and outcomes. Properly preserved analog images may
last decades with original fidelity and 100 years or more with
mild degradation. Digital images may not last much longer.
Challenges in the evolution of technology lead to viewing
problems (incompatibilities in hardware), scrambling issues
(changes in compression algorithms), inter-relation limita­
tions (expired webpages or hyperlinks), custodial problems
(where the data resides), translation issues (how to read old
storage with new technology) to name a few. If digital con­
cerns are solved, images could last centuries or more.5 Build­
ing a digital database and engaging in periodic data mining
is a core component of self-improvement in clinical care. The
advent of digital photography eliminates concerns about lack
of space, difficulties in storage like degradation of image
quality, the ability to compare past and present results over
large series and related issues. However, they are subject to
their own vagaries. Old retrieval technologies (floppy disks,
CDs , etc.) are subject to catastrophic failure. For example, a
scratch on a transparency may slightly degrade the quality of
the image, while the same event in a digital image may make
it unreadable. Digital images must be backed up, and the
methodologies rapidly change necessitating continual hard­
ware upgrades. The best storage methods have changed 5–10
times in the last 20 years from floppy disk to magneto-optical
disks, magnetic tape back-up, compact discs (CDs), digital
video discs (DVDs), USB flash drives, portable hard drives,
network attached storage drives, and more recently, “in the
cloud” at a remote data storage center on the internet. Much
like the evolving standards in business and research regard­
ing storage of e-mail and digital documents for potential legal
cases, our de facto standards dictate that photographs must be
preserved, organized, properly referenced and identified,
while easily retrievable.
Informed consent is a key part of medical record-keeping,
and photography is essential to proper medical records.
Almost every patient understands that photographs are part
of the medical records. In fact, many insist on seeing “before
and after” examples in their initial consultation, the best time
to establish the necessity of accurate documentation. Some
patients have a strong need for privacy; however, most sur­
geons will refuse to operate on a patient who refuses medical
photography. Patients understand they have control and
options on how their pictures will be used. Some practices
allow only internal records in their private chart, others may
permit sharing with other patients in consultation without
identifying data, and some are comfortable with unrestricted
use on the internet, in print, and television advertising. A
thorough, detailed consent form specifically for the use of
images is necessary for a proper medico-legal record.1 Consent
forms from the American Society of Plastic Surgeons are avail­
able for member surgeons.6 Photography’s utility as a research
and interpretative tool in our field is without question.7 Com­
parison of how our journals have progressed from the first
decade of the 20th to the 21st century shows that our journals
have gone from black and white to color photographs, to
online digital images in low and high resolution, to online
video. Three-dimensional simulations that allow a “fly
through” of the anatomy have been available for several years.
Information density in images is an order of magnitude greater
than the written word. With decreasing costs in the digital era,

77
Standards in capturing images
Key principles
• The same camera and photographer should be used.
Changing a digital camera (and therefore the color and
white balance) essentially alters the pixel resolution,
photonic sensitivity and hardware image processing.
• Shutter speed and aperture must remain the same.
Positioning of the patient and photographer in the room
should not vary.
• Guide marks on the floor may be required; flash equipment
and lighting should not vary.
• Adequate lighting is essential. Shutter speed should be at
1/60 of a second or faster.
• On digital cameras, keep the magnification factor
comparable with a 35 mm camera 100 mm lens for
essentially all images except full body views, where a view
comparable to a 50 mm lens may be used.
• Focus by moving the camera closer or farther from the
patient and note the position of the mechanized zoom lens
barrel in relation to the camera body.
• Do not change the white balance, and keep it in sync with
the lighting used (often flash or fluorescent) on a medium
blue background.
• While modern cameras often contain 16 megapixels or
more, generally more than 6 megapixels are not required.
• Space for digital images is not an issue in this era of
terabyte hard drives, and the speed is easily adequate for
rapid access of data.
• More images than will likely be used in a career can be
stored on portable drives.
compression and software algorithms of the camera. Indirect
are listed as lighting, metering, depth of field, color temperature
of lighting and output method. Both categories are easily con­
trolled by retaining consistent techniques from visit to visit (see
Key principles box).
Background
Medium blue or 18% gray featureless backgrounds provide
the best skin tones and affect exposure least. White or black
backgrounds affect exposure on the most commonly used
camera setting (matrix metering), so the mode must be
changed to spot mode metered on the skin in the center of the
field. However, the sharp contrast will not create a natural
skin coloring. Standard blue towels used in surgery are close
enough to ideal to be used without problems, but green surgi­
cal towels are not.
White balance
Accurate, lifelike color reproduction is dependent on neutral­
ity, an equal distribution of colors in the white, gray and black
in the image to ensure accuracy of hue. A color-balanced image
contains all hues in equal proportions of illuminating white
light. Unfortunately, different types of reference white points
exist in various environments. Indoor scenes lit by incandes­
cent lamps are distinctly different from daylight. Fluorescent
lights come in various shades of blue. Operating room lighting
is variable in color, temperature, angle, and distance from the
patient. The white balance adjustment attempts to capture
neutral colors by compensating for these changes. Modern
digital cameras have numerous settings like daylight, fluores­
cent 1 and 2 (or high and low), and auto white balance, among
others. The auto white balance setting is often misled by the
pulsations of overhead fluorescent lights and may produce
variations from image to image. Flash lighting minimizes the
effect of ambient light and forces the use of smaller aperture,
lower ISO, and shorter exposures. Ideally, a multiple flash
system in a dedicated photography studio is used to eliminate
these problems in order to capture flesh tones consistently and
accurately. Single on-camera flash is inadequate due to shad­
owing effects in all backgrounds except black.
Lens aperture and shutter speed
There is a delicate balance among aperture, lighting, and
shutter speed. A narrow aperture (high F-stop) provides
increased depth of field compared to a larger aperture. Too
wide an aperture (low F-stop) allows for a shallow depth of
field, which creates difficulty, for instance, in capturing simul­
taneous changes in the crow’s feet area and the submentum.
An F-stop of 16 or less should be used, with consistency
maintained over pre- and postoperative settings. Skin with
darker pigmentation may require a larger F-stop.
Shutter speed controls the amount of time that light is
exposed to the image sensor. Increased shutter speed allows
less light in, while decreased shutter speed results in blurry
images with subject movement.
Composition and positioning
Full face
In the anterior–posterior (AP) view, the superior border of the
head must be framed by a small amount of background, about
10% of the vertical height of the image or 2 cm above the vertex
of the skull. The inferior border of the image should stop just
below the suprasternal notch. The Frankfort horizontal plane
connects the infraorbital rim to the tragus and is kept parallel
to the floor. For the frontal view, the ears can be used to ensure
proper positioning. In the lateral view, the patient’s body and
head should be facing 90° from the focal plane of the camera.
The eyebrows should be superimposed. While some cropping
of the occipital region is acceptable, in general, lateral views
should include the full view. Oblique views should be taken
at 45° and, in this view, the tip of the nose should protrude
slightly beyond or rest just at the contour of the distal malar
eminence. Five standard views are taken, an AP, two oblique
and two lateral, right and left for each of the latter two (Fig.
7.1). When indicated, the malar eminence may be imaged,
generally the bird’s eye view is preferred over the worm’s
eye view, unless a particular feature of anatomy is involved.
Musculature should be relaxed in all photographs unless
otherwise specified.
Eyes
The same five image views (anterior, two laterals and oblique
views) are part of the basic set for the eyes. Close-up images
of the eyes should include a small border of forehead skin
above the eyebrows and extend inferiorly to the upper lip at
the nasal spine. For the lateral and oblique views, positioning

78
CHAPTER 7 • Digital imaging in plastic surgery
Fig. 7.1  Full face. Five standard views: (A) Anterior–
posterior. (B) Right oblique. (C) Right lateral. (D) Left
oblique. (E) Left lateral.
A
B
C
D
E
is similar to the views of the head honoring the superior and
inferior borders herein. Additional views are essential and
include the following at a minimum: (1) closed eye view to
highlight the superior tarsal sulcus and fold, and (2) upward
gaze to highlight inferior orbital fat pockets and the lower lid
margin. A squinting view consists of open eyelids with con­
tracting of the superior and inferior orbicularis oculi to feature
the impact of muscle action on eyelid shape and function.
Occasionally, a view with tightly-closed eyelids to highlight
the orbital orbicularis, zygomaticus muscles and others is
required for certain surgical procedures (Fig. 7.2).
Glabella
Images of the corrugator muscles may be taken at rest and on
full contraction to document wrinkling on the validated four-
part glabellar rhytid scale (Fig. 7.3). Full face images are often
used; however, the superior border is best cut off at the location
(or former location in baldness) of the anterior hairline and the
inferior border is often positioned midway between the radix
and the tip of the nose on a horizontal line through the lower
margin of the malar eminence. The closer view provides more
detail of pore size, eyebrow position and skin texture. Oblique
and lateral views are generally not necessary.
Nose
The superior margin of the nasal view is essentially the same
as for the eyes – just above the eyebrows. However, the
inferior margin is at the upper lip or between the closed lips.
In addition to the five basic views, worm’s eye view or chin-up
view is included (Fig. 7.4). The superior and inferior borders
are the anterior scalp line and the mentum, respectively. When
muscular release at the dorsum or nasal spine is contemplated,
dynamic pictures of contraction should be included.
Lips, nasolabial folds, and mentum
The superior border is on a line just above the nasal tip and
includes the alar base, while the inferior border allows a small
amount of background to show below the chin (Fig. 7.5). The
lips should be slightly parted to detect features in the mucosal
surfaces near the intersection of the upper and lower borders.
When injections into vertical lip lines are performed, the
pursed lip or orbicularis-contracted view is added. Additional
views may include contraction of the mentum when toxins or
soft-tissue fillers are part of the therapeutic intervention.
Dental occlusal views
When intraoral or two-jaw surgery is considered, dental
occlusal views are required, and transparent cheek retractors
must be utilized.
Ears
Adequate visualization of the ears requires that the hair must
be retracted. Anterior and posterior views should include the

79
Standards in capturing images
Fig. 7.2  Eyes. Standard views: (A) Anterior–posterior view. (B) Anterior–posterior view with upward gaze. (C) Anterior–posterior with eyes closed gently. (D) Anterior–
posterior with eyes closed tightly. (E) Right oblique in forward gaze. (F) Right lateral in forward gaze. (G) Left oblique in forward gaze. (H) Left lateral in forward gaze.
A
B
C
D
E
F
G
H
Fig. 7.3  Glabella. (A) Glabella relaxed. (B) Glabella contracted. (C) Glabella post relaxed. (D) Glabella post contracted.
A
B
C
D

80
CHAPTER 7 • Digital imaging in plastic surgery
Fig. 7.4  Nose. Standard views: (A) Anterior–posterior. (B) Right oblique. (C) Right lateral. (D) Left oblique. (E) Left lateral. (F) Tilted head view.
A
B
C
D
E
F

81
Standards in capturing images
removed. There are three basic variations in arm positioning
on the lateral view of the breast: (1) arms at side; (2) arms on
hips; and (3) arms behind the lower back. The most common,
in the author’s experience, is the former. Oblique views may
be taken in positions 1 and 2 above, while occasionally AP
views are taken with arms above the head. Dynamic pectoralis
animation deformities may be highlighted on AP views with
hands pushing against the hips.
Lower trunk, abdomen, and buttocks
The five standard views are supplemented with a posterior
view (Figs. 7.7, 7.8). When the buttocks are the focus of the
image, no panties are used. It is essential to use disposable,
full head and supplemental mid-range views should extend
from the upper neck to above the occipital ridge to bring the
ear more fully into the image. Lateral images should include
close-up composition with the vertical height roughly twice
the height of the ear itself.
Chest and breast
Variations in the configuration of the trunk dictate that the
principle of bordering the image based on regional anatomy
is critical in these images (Fig. 7.6). Vertical borders should
range from above the suprasternal notch in the lower third of
the neck to below the mid-costal margins. Patients should be
disrobed above the waist, and all visible jewelry must be
Fig. 7.5  Lips, nasolabial folds and mentum. AP view: (A) Pre- and (B) post-procedure. Right oblique: (C) Pre- and (D) post-procedure. Right lateral: (E) Pre- and
(F) post-procedure. Left oblique: (G) Pre- and (H) post-procedure. Left lateral: (I) Pre- and (J) post-procedure.
A
B
C
D
E
F
G
H
I
J

82
CHAPTER 7 • Digital imaging in plastic surgery
A
B
C
D
E
F
Fig. 7.6  Chest and breast. AP view: (A) Pre- and (B) post-procedure. Right oblique: (C) Pre- and (D) post-procedure. Right lateral: (E) Pre- and (F) post-procedure.
Continued

83
Standards in capturing images
Left oblique: (G) Pre- and (H) post-procedure. Left lateral: (I) Pre- and (J) post-procedure.
inferior popliteal fossa or just above the patella. The photo­
graphic background must extend onto the floor, all the way
out of the frame for the lower view.
Hands and feet
A full dorsal and volar view is required. In some patients,
oblique views are required as well. Dynamic views in flexion
and extension are an essential component of the complete
medical record (Fig. 7.10).
Specialty views
Other regions of anatomy follow the same principles: (1) clear
margins of background or adjacent anatomy; (2) AP, lateral and
oblique views; (3) dynamic views as indicated; and (4) macro
views when required to demonstrate features of anatomy.
In the hospital and operating room
The compact digital camera has largely supplanted the 35 mm
film camera in the emergency department and on the go.
blue paper photographic panties (“modesty garments”) to
standardize the clothing, color and white balance. Almost
invariably otherwise, a patient would arrive on a subsequent
visit with different color, contour and texture of undergar­
ments. In addition, sometimes patients will arrive with a
distracting, different dark-light tan line in summer climes.
Legs should be slightly apart to allow viewing of the groin
against the light background. Feet should be aligned with
appropriate tape marks on the floor.
Lower extremity
The five standard views should also be supplemented by a
posterior view (Fig. 7.9). The patient should stand comfort­
ably erect with arms folded above the chest. Feet should be
approximately shoulder width apart, aligned with appropri­
ate tape marks on the floor. For a full view, the upper margin
should be found at the level of the umbilicus and the lower
margin inferior to the toes or heel depending on the view. For
the half upper or lower view, the lower or upper margin,
respectively, should be just below the knee at the level of the
G
H
I
J
Fig. 7.6, cont’d

84
CHAPTER 7 • Digital imaging in plastic surgery
Fig. 7.7  Lower trunk, abdomen and buttocks. Standard views: (A) Anterior–posterior. (B) Right oblique. (C) Right lateral. (D) Left oblique. (E) Left lateral. (F) Posterior
view.
A
B
C
D
E
F

85
Standards in capturing images
Fig. 7.8  Lower abdomen, buttocks, and thighs. Standard views: (A) Anterior–posterior. (B) Right oblique. (C) Right lateral. (D) Left oblique. (E) Left lateral. (F) Posterior
view.
A
B
C
D
E
F

86
CHAPTER 7 • Digital imaging in plastic surgery
Fig. 7.9  Lower extremity. Standard views:
(A) Anterior–posterior. (B) Right lateral. (C) Left
lateral. (D) Posterior view.
A
B
C
D
Results are excellent, and convenience is high. However,
when expense is not an issue, many surgeons prefer SLR-like
full-frame (35 mm diagonal) digital cameras in the operating
room. Operating room lights vary among hospitals and rooms.
On-camera hot shoe flashes for large format cameras are of
much higher quality than built-ins for compact cameras. This
allows for consistency in color balance, as ambient light does
not provide the illumination for the exposure. Flashes that are
designed for medical photography include the ring flash,
dual-point flash, and the ring and point combination flash.
The ring flash is particularly useful for intraoral anatomy and
intraoperative photography, though it may wash out color
and skin tones. Standardized use of auto white balance
without a flash in a compact camera is a close second. Macro-
mode or close-up focusing may put sterility of the operative
field at risk and is more problematic. Automatic exposure
reliably creates an image with proper lighting in the operating
room.
The need for proper composition of the picture remains in
the operative setting or emergency department and may be
overlooked amidst other priorities. The framing principles
already discussed should be followed to the extent allowed
by the sterile field and drapes. Anatomic landmarks should
be included at the borders of the frame. Shiny instruments,
stained surgical drapes, gauze or glare from overhead lights
must be eliminated or covered. Often the overhead lighting is
harsh and must be removed from the field to prevent over­
saturation of the image.
Archiving and image management
Cameras
There are many excellent resources in the literature for discus­
sions on film photography. The era of light sensitive silver
halides suspended in a gelatinous emulsion in film photogra­
phy resides in niche markets, essentially outside the field of
plastic surgery.16 Film or analog photography had an amazing
160-year run from the 1840s, before being supplanted by
digital, around the new millennium.17 Because the overwhelm­
ing majority of cameras in use today are digital, we will
concentrate here on digital. Like a film, digital imagers gener­
ally consist of red, green, and blue filters. Film has continuous
stacked emulsions or layered films of colors, while digital uses
variations on a checkerboard pattern of cells to filter light. In
the Bayer pattern, most commonly found in digital cameras,
every other pixel is green, while one in four is either red or
blue. A few cameras, like those from Canon, use a comple­
mentary metal oxide semiconductor (CMOS) sensor, but most
use charged couple devices (CCDs). In the former, each
element contains its own transistor and circuitry providing for
independent reading of data. When photons strike a CCD,
charges propagate down each row of the checkerboard pattern
and this limits the speed with which they can propagate.
Newer CCDs have triple-stacked sensors (red, green, and
blue, RGB) that lower resolution, but increase sensitivity.

87
Archiving and image management
components. However, the plastic surgeon will require some­
thing more capable, albeit a large format, 35 mm size digital
camera is not truly essential for adequate pre- and postopera­
tive photographs in the proper setting. Mobile phone cameras
are inadequate, as are entry-level compact devices. Lifestyle
and fashion cameras are not suitable.
Well-designed cameras of either type will capture excellent
images.
Choosing a digital camera can be overwhelming due to the
myriad of choices available. Even a simple point and shoot
can take excellent photos due to unrelenting commercial
competition among manufacturers and the decreasing cost of
Fig. 7.10  (A–G) Hands: standard views.
A
B
C
D
E
F
G

88
CHAPTER 7 • Digital imaging in plastic surgery
refers to a display device or content having horizontal resolu­
tion on the order of 4000 pixels. Under the previous conven­
tion, 4K would be equivalent to 2160p.
Secure digital media come in a regular or high capacity
format (SD, SDHC, or SDXC). Recently, 128 GB and even
512 GB models are available worldwide with speed ade­
quate to capture video at high resolution. Micro-SD cards
are generally relegated to mobile phone cameras and data
storage.
Memory card readers are widely available and inexpensive,
like memory cards. Data can be uploaded to a computer via
USB cable attached to the camera from the computer. However,
it is quite common to remove the card, insert a spare into the
camera and read the data from a card reader.
With the advent of the multi-terabyte hard drive, both
desktop and portable, storage of thousands or tens of thou­
sands of pictures is no longer an issue. Maintaining a disci­
plined, regular back-up program, however, is as essential as
any record-keeping in the practice. At least two copies should
be maintained onsite, and another offsite at a remote location
to obviate water, fire, or earthquake damage.
File formats
There are dozens of data structures or architecture, also known
as file formats. We will only concentrate on a few of the most
commonly used: TIFF, JPG (or JPEG, for joint photographic
experts group), Photoshop, GIF and RAW. Fortunately, almost
any software will convert one still image type to another.
However, it is important to understand their advantages and
disadvantages.
TIFF is best used for print reproduction because it is a
bit-mapped (like a printer) or raster Tag Image File Format. It
supports 24-bit color depth per pixel, dimensions and color
look-up tables “tagged” to the header of the data file. The way
the tag specification is written gives rise to various versions
of a TIFF file. Lossless compression with the LZW algorithm
makes compression safe for data quality.
JPEG (JPG) is perhaps the most common file type, and it is
“lossy”. Compression can be chosen from a 12-part scale from
none to as much as 90%, while data quality diminishes
accordingly. For quick exchange of images via email, this is
ideal. Minimal compression almost retains original image
fidelity. There is almost no software that cannot easily read
this format, and with wide latitude in software storage
parameters there is great flexibility.
Photoshop (PSD) is a proprietary format of Adobe Systems
Corporation (San Jose, CA), but is so commonly used as to
almost be a standard. Color management, 48-bit color and
layers are supported.
RAW format varies from camera to camera because it is
dependent on the hardware interface with the light capturing
chip (CCD or CMOS) inside the camera. These files are some­
times called digital negatives because they fulfill the same role
as negatives in film photography. It is the truest image as there
is no white balance, color processing, compression, sharpen­
ing, or other manipulation of the data. Because the data is
unprocessed, capture rates can be much faster with higher
throughput. RAW has numerous advantages over JPEG
including higher image quality, finer control, non-destructive
change capability, and lossless compression. However, camera
RAW file size is typically 2–6 times larger than JPEG files, and
There were “resolution wars” in marketing cameras 10
years ago, but gladly those are over. Resolution is most often
used to describe how many pixels are in the array. Minimum
sizes now are >3000 × 2000 or 6 megapixels. Actually, most
cameras are capable of ≥16. The number of pixels sets the
upper limit of image quality, but not the lower limit. Another
more important gauge of resolution is how sharply an image
resolves fine detail, often depicted by extremely small, narrow
lines. This is a more functional definition, though less com­
monly used.
The enthusiast compact category is generally adequate for
plastic surgeons to use on a daily basis, if the additional
expense of a prosumer or professional digital camera is not
within the budget. Numerous features are available: high
pixel count, large sensor size, an advanced hardware algo­
rithm for interpreting the light image that strikes the chips,
zoom and video capability are highly valued. Perhaps most
important is the quality of the glass and the design of the
optics in the lens itself. Features such as rapid shutter speed,
geotagging, or very large aperture are not so critical in the
patient-care setting. However, enthusiast cameras are capable
of capturing images almost indistinguishable from higher end
models in a controlled setting such as the plastic surgeon’s
photography studio or the operating theater. Prosumer
cameras have many of the features of a digital single lens
reflex (DSLR). In essence, a plastic surgeon only requires a
50 mm equivalent and a 100 mm equivalent lens setting.
Advanced computer design of camera zoom lenses has
allowed for excellent shooting characteristics with compact
cameras in both the 50 and 100 mm range, with minimal
degradation of image quality. In other words, it is possible to
get along with an enthusiast or prosumer camera in most
situations.
Professional DSLRs are larger, heavier, machined to precise
specifications, resistant to moisture and impact and sturdy,
with full-frame 36 × 24 mm sensors that can potentially capture
up to 25 megapixels in one image. Medium format cameras
with pixel counts up to 60 million are rarely found or required
in our specialty. The mirrorless interchangeable-lens camera
is a newer class of digital system cameras that is gaining
popularity. While they do not have a mirror reflex optical
viewfinder, these cameras have been manufactured with
various sensor sizes up to full-frame. Compared to DSLRs,
mirrorless cameras are smaller and sturdier, while maintain­
ing the versatility of interchangeable lenses. Almost all
enthusiast cameras allow for high-definition video recording
of several minutes duration. This is entirely adequate for
documenting repeated key steps in an operative procedure,
while not reaching the standards of a professional
cinematographer.
Format
Storage
Digital memory cards come in a variety of types including
compact flash and secure digital (SD). They are capable of
transferring data at up to 30 MB/s for high resolution video
such as full HD or 4K video. HD resolution may be 720p based
on vertical dimension (1280 pixels wide by 720 pixels high) or
1080i/1080p (1920 by 1080 pixels), with horizontal lines
scanned interlaced (i) or progressively (p). 4K resolution

89
New frontiers
interactive learning to engaging in mock surgery with haptic
feedback and complete with unexpected complications.19
Surgical planning is more easily achievable, and requires less
computer power and complexity in programming. Organized
medicine was challenged by the Institute of Medicine Report,
To Err Is Human: Building a Safer Health System in 2000.20 It has
been estimated that 44 000 deaths occur yearly due to medical
errors, the seventh leading cause of death. Many of these
occurred during surgery, as a result of surgical planning or
postoperative care.
Computer-based virtual surgical planning (VSP) is gener­
ally available in plastic surgery from commercial companies
(Nex-Tech, Stryker, Canfield, and Crisalix). Standardization
of patient topographical measurements can be utilized to
enhance preoperative planning and improve postoperative
outcomes. More elaborate mannequin-based systems are
becoming more mainstream due to the advent of 3D printing.
Customized implants and prostheses have been used through­
out plastic surgery, and the integration of precise anatomical
topography in the preoperative setting with 3D printing could
revolutionize the world of implants in plastic surgery.
New frontiers
Three-dimensional surface imaging
In conventional medical procedures, diagnosis, treatment,
and outcome are typically judged by objective criteria. The
patient’s subjective feelings are of relevance, but of a second­
ary nature. In plastic surgery, on the other hand, the healthcare
model is often one of wellness and enhancement, the patient
is not ill or diseased and therefore the diagnosis, treatment,
and outcome may be dominated by the patient’s subjective
assessment of an elective surgical procedure. Consequently,
even the most technically perfect surgical procedure can lead
to patient dissatisfaction, should the result not meet aesthetic
and psychological expectations. Failure to meet these expecta­
tions can lead to the need for re-operation, increased medico-
legal risk and additional costs directly to the surgeon.
Furthermore, the market dynamics of cosmetic surgery are
strongly driven by patient referrals, which again are based
upon patient satisfaction. In breast augmentation surgery, for
example, it can be advantageous that the patient is collabora­
tively involved in the process of implant selection, supported
by the surgical team, and that the patient ‘buys in’ to the
selection process with enthusiasm, confidence and conviction.
One of the major reasons to undergo plastic surgery is to
change the external appearance of the patient; a central ques­
tion that all patients have in common is “how should I look
after my operation?” One way to answer this is through 3D
imaging.21
Today, 3D physics-based finite element analysis (FEA)
technology can provide patients with a simulated view of their
anatomy in a postoperative condition. While there are other
methods to show the patient a probable outcome – such as
special bras and sizers, computer slide shows with various
before/after photographs of previous patients, collecting
photographs from magazines, and morphing software based
on photographs – all have limitations. All these methods
require realistic imagination by the patient. State of the art
technology allows patients to see themselves from varying
lack of standard RAW image format requires more specialized
software to open RAW files.
Video, unfortunately, is plagued by numerous incompatible
standards. Even file formats with identical suffixes may be
unreadable by other software or hardware, e.g., MP3 or MP4
(motion picture experts group 3 or 4) are often not readable
unless the original software used to create the file is available.
A software codec (coder-decoder) is required and often not
cross-platform for PC or Mac. That rigorous discussion awaits
another setting.
Image attributes, metadata, and retrieval
As the images are safely transferred to storage media, critical
new information must be attached to the data. Modern
cameras use a format called EXIF for recording camera type,
lens, date, time, shutter, aperture, and many other items. Even
more critical for plastic surgery is information like patient age,
sex and weight, ICD-10 diagnostic codes, CPT procedural
codes, type of implant used, pre- or postoperative status, date
of original surgery and other critical pieces of medical data.
These are proprietary to individual software packages and
make changing platforms difficult after even a few months or
a year of use. What once was a demanding and difficult
exercise is now made transparent and easy by improved
software interface designs.
The Health Insurance Portability and Accountability Act of
1996 (PL 104–91) has resulted in a major increased emphasis
on patient privacy among other concerns. The broad interpre­
tation of this law includes any part of the medical record. The
American Recovery and Reinvestment Act of 2009 extended
Privacy and Security Provision of HIPAA to business associ­
ates of covered entities and provides for stiff civil and criminal
penalties for violation. Loss or dissemination of digital images
can be much more serious than film photographs, with the
risk of electronic data “going viral” over the internet to mil­
lions of people.
Digital image processing
Measurement and analysis
Orthognathic surgery has rested on the principles of image
measurement and analysis since the early days of film pho­
tography. Measurements were made directly on photographs
or transparencies and taken to the operating room to guide
surgical osteotomies. Now these measurements can be made
directly on the digital image. A well-developed model of cleft
lip repair has been incorporated into the training program for
a large charitable organization prior to surgeons going over­
seas on mission work.
Identifying and highlighting anatomic landmarks for the
medical record in breast augmentation surgery increasingly
has become a part of the preoperative consultation.18 It is the
first step in building a predictive model for planning pocket
dissection, choosing implant size, evaluating postoperative
size and may lead over time to reduced rates of re-operation.
Planning and simulation
The term surgical simulation has been broadly defined
to include anything from computer-assisted tutorials to

90
CHAPTER 7 • Digital imaging in plastic surgery
performance. It obligates a commitment to production values,
editing, composition, and a host of skills residing in the pro­
fessional medical videographer. Short videos can document
features such as range of motion, bulk strength and tone,
elasticity and even aesthetic contours in motion. However,
long compositions require expert direction, videography and
editing. One potentially cost-effective solution is the use of
commercially available amateur point-of-view video systems
in the operating room. The future will certainly increasingly
incorporate digital video in the practice of plastic surgery.27
Presentations
In the era of digital media, the art of medical presentation
should be mastered by every plastic surgeon to educate
patients, students of surgery, and other healthcare providers.
The nature of our specialty encourages photography and
videography to take center stage in a digital slideshow.
angles in 3D before the operation, increasing communication
with the surgeon by interacting collaboratively with the image,
and simulating the outcome of the surgical procedure.
Techniques for 3D modeling include, on one hand, expen­
sive, space-limited and obsolescence-sensitive hardware
scanners, and on the other hand, those based on the physical
reconstruction of the body from 2D photographs. The former
requires a large upfront investment amortized over time. The
latter method functions on a pay-as-you-go basis and takes
advantage of ease of use, simplicity, and minimal interference
with the way the surgeon performs a consultation. When no
special hardware is required, photographs are coupled with
anatomical measures and physiologically-based data process­
ing and simulation. Whatever technique employed, 3D and
virtual reality are the future.22–26
Video
Much of what has been said of 3D technology can be said of
video medical records, other than the simulation aspects.
Motion picture film has been a part of medicine for decades
for surgical education, while digital video as a part of a
medical record is a recent and evolving innovation, not yet
standard of care. Almost every modern digital camera has
the capability of capturing video clips. However, the lenses
are not specifically designed for professional quality where
heavy, expensive equipment is required and more computer
power and capability is mandatory. Creation and routine
use of detailed video is beyond the scope of most busy
plastic surgery practices, though it provides a method to
augment surgical education and analyze personal operative
Key principles
• When creating slides, think big font and limited text.
• Cite examples and use case presentations.
• Utilize appropriate animations to illustrate techniques and
concepts.
• Use emphatic and descriptive gestures during live
presentation.
• Ask effective questions to engage the audience.
1. Reed ME, Feingold SG. Ethical consideration. In: Nelson GD,
Krause JL, eds. Clinical Photography in Plastic Surgery. Boston: Little,
Brown; 1988:129–153.
3. Chávez AE, Dagum P, Koch RJ, et al. Legal issues of computer
imaging in plastic surgery: a primer. Plast Reconstr Surg.
1997;100:1601–1608. Medical simulation adds a new dimension to patient
consultation. While potential legal concerns accompany this technology
(such as the potential to enter into an “implied contract”), the savvy
practitioner can responsibly employ this technology and minimize legal
risk.
4. Mirror Image Software Suite, Canfield Imaging Systems, 253
Passaic Avenue, Fairfield, NJ 07004–02524 USA. “Mirror” is a
powerful and user-friendly clinical imaging suite. Capable of tasks from
image manipulation to advanced database functionality.
7. Parker WL, Czerwinski M, Sinno H, et al. Objective interpretation
of surgical outcomes: is there a need for standardizing digital
images in the plastic surgery literature? Plast Reconstr Surg.
2007;120:1419–1423.
10. Zarem HA. Standards of photography. Plast Reconstr Surg.
1984;74:137–144.
12. Galdino GM, Vogel JE, Vander Kolk CA. Standardizing digital
photography: it’s not all in the eye of the beholder. Plast Reconstr
Surg. 2001;108:1334–1344. The intricacies of selecting a digital camera
ideal for patient photography are considered.
13. DiBernardo BE, Adams RL, Krause J, et al. Photographic standards
in plastic surgery. Plast Reconstr Surg. 1998;102:559–568.
14. Plastic Surgery Educational Foundation/Clinical Photography
Committee. Photographic Standards in Plastic Surgery. Arlington
Heights: Plastic Surgery Educational Foundation, Clinical
Photography Committee; 1991. A very practical guide to achieving high
quality, standardized patient photographs is presented. A compact PDF is
available for download.
22. Smith DM, Oliker A, Carter CR, et al. A virtual reality atlas of
craniofacial anatomy. Plast Reconstr Surg. 2007;120:1641–1646. An
interactive 3D computer graphics model of craniofacial anatomy is
described. Methods of creation and future applications are discussed.
25. Smith DM, Aston SJ, Cutting CB, et al. Applications of virtual
reality in aesthetic surgery. Plast Reconstr Surg. 2005;116:898–906.
Access the complete reference list online at

90.e1
References
References
1. Reed ME, Feingold SG. Ethical consideration. In: Nelson GD,
Krause JL, eds. Clinical Photography in Plastic Surgery. Boston: Little,
Brown; 1988:129–153.
2. Thomas JR, Freeman MS, Remmler DJ, et al. Analysis of patient
response to preoperative computerized video imaging. Arch
Otolaryngol Head Neck Surg. 1989;115:793.
3. Chávez AE, Dagum P, Koch RJ, et al. Legal issues of computer
imaging in plastic surgery: a primer. Plast Reconstr Surg.
1997;100:1601–1608. Medical simulation adds a new dimension to
patient consultation. While potential legal concerns accompany this
technology (such as the potential to enter into an “implied contract”),
the savvy practitioner can responsibly employ this technology and
minimize legal risk.
4. Mirror Image Software Suite, Canfield Imaging Systems, 253
Passaic Avenue, Fairfield, NJ 07004–02524 USA. “Mirror” is a
powerful and user-friendly clinical imaging suite. Capable of tasks from
image manipulation to advanced database functionality.
5. Besser H. Digital longevity. In: Maxine S, ed. Handbook for Digital
Projects: A Management Tool for Preservation and Access. Andover:
Northeast Document Conservation Center; 2000:155–166.
6. American Society of Plastic Surgeons. Authorization for and Release of
Medical Photographs/Slides and/or Video Footage in Patient Consultation
Resource Book. Arlington Heights: American Society of Plastic
Surgeons; 2009.
7. Parker WL, Czerwinski M, Sinno H, et al. Objective interpretation
of surgical outcomes: is there a need for standardizing digital
images in the plastic surgery literature? Plast Reconstr Surg.
2007;120:1419–1423.
8. Riml S, Piontke AT, Larcher L, et al. Widespread disregard of
photographic documentation standards in plastic surgery: a brief
survey. Plast Reconstr Surg. 2010;126:274e–276e.
9. Morello DC, Converse JM, Allen D. Making uniform photographic
records in plastic surgery. Plast Reconstr Surg. 1977;59:366–372.
10. Zarem HA. Standards of photography. Plast Reconstr Surg.
1984;74:137–144.
11. Galdino GM, Swier P, Manson PN, et al. Converting to digital
photography: a model for a large group or academic practice. Plast
Reconstr Surg. 2000;106:119–124.
12. Galdino GM, Vogel JE, Vander Kolk CA. Standardizing digital
photography: it’s not all in the eye of the beholder. Plast Reconstr
Surg. 2001;108:1334–1344. The intricacies of selecting a digital camera
ideal for patient photography are considered.
13. DiBernardo BE, Adams RL, Krause J, et al. Photographic standards
in plastic surgery. Plast Reconstr Surg. 1998;102:559–568.
14. Plastic Surgery Educational Foundation/Clinical Photography
Committee. Photographic Standards in Plastic Surgery. Arlington
Heights: Plastic Surgery Educational Foundation, Clinical
Photography Committee; 1991. A very practical guide to achieving high
quality, standardized patient photographs is presented. A compact PDF is
available for download.
15. American Society of Plastic and Reconstructive Surgeons, Inc.
Clinical Photography in Plastic Surgery. Arlington Heights: American
Society of Plastic and Reconstructive Surgeons, Inc.; 1995.
16. Hirsch R. Exploring Color Photography: From Film to Pixels. 5th ed.
Burlington: Focal Press; 2011.
17. Ang T. Digital Photographer’s Handbook. 4th ed. New York: Dorling
Kindersley; 2009.
18. Tebbetts JB, Adams WP. Five critical decisions in breast
augmentation using five measurements in 5 minutes: the
high five decision support process. Plast Reconstr Surg. 2006;
118(7 suppl):35S–45S.
19. Dawson S. A critical approach to medical simulation. Bull Am Col
Surg. 2002;87:12–18.
20. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human:
Building a Safer Health System. Committee on Quality of Health Care in
America, Institute of Medicine. Washington DC: The National
Academy Press; 2000.
21. Jacobs RA, the Plastic Surgery Educational Foundation DATA
Committee. Three-dimensional photography, safety and efficacy
report. Plast Reconstr Surg. 2001;107:276–277.
22. Smith DM, Oliker A, Carter CR, et al. A virtual reality atlas of
craniofacial anatomy. Plast Reconstr Surg. 2007;120:1641–1646. An
interactive 3D computer graphics model of craniofacial anatomy is
described. Methods of creation and future applications are discussed.
23. Rosen JM, Long SA, McGrath DM, et al. Simulation in plastic
surgery training and education: the path forward. Plast Reconstr
Surg. 2009;123:729–740.
24. Smith DM, Aston SJ, Cutting CB, et al. Designing a virtual reality
model for aesthetic surgery. Plast Reconstr Surg. 2005;116:893–897.
25. Smith DM, Aston SJ, Cutting CB, et al. Applications of virtual
reality in aesthetic surgery. Plast Reconstr Surg. 2005;116:898–906.
26. Chang JB, Small KH, Choi M, Karp NS. Three-dimensional surface
imaging in plastic surgery: foundation, practical applications, and
beyond. Plast Reconstr Surg. 2015;135:1295–1304.
27. Graves SN, Shenaq DS, Langerman AJ, et al. Video caputure of
plastic surgery procedures using the GoPro HERO 3+. Plast Reconstr
Surg Glob Open. 2015;3:e312.

8 
Patient safety in plastic surgery
Bruce Halperin†
SYNOPSIS
■ Modern medicine has greatly reduced the risk of surgery.
■ Identifying which patients are at greatest risk for surgery starts the risk
reduction process.
■ Identification of medical factors leading to complications helps prevent
untoward outcomes.
■ Specialized care for the liposuction patient.
■ Specialized care for the patient having facial aesthetic surgery.
■ Avoiding fire in the operating room.
■ Protocol-based systems for risk reduction.
■ Reducing patient risk through optimal patient care.
■ Do it better, do it safer.
The risk of having surgery
The decision to perform surgery to correct a defect or medical
condition begins a cascade of decision-making and, by neces­
sity, a series of compromises. It is the underlying desire of the
medical profession to prolong and enhance the lives of patients
who seek attention. Since the beginning of the practice of
medicine it has been understood that undesired outcomes
may occur. The acceptance by the patient of undesired
outcome has changed over the course of medical history. As
medical science has progressed, the expectations of patients
and the medical profession have risen. As medical science
understands ever-increasing levels of human biologic com­
plexity, the expected outcome from medical intervention may
change yet again. It is not yet clear to the practicing physician
or public as to the fundamental cause of undesired medical
outcomes.
It is clear that many of the undesired outcomes we now see
are a result of failure to implement knowledge we already
possess. We must further question whether it is our healthcare
delivery system that is in fact responsible for many of the
undesired outcomes that our patients face. When we decide
to perform a surgical procedure we accept the risk of unde­
sired outcome. Using the knowledge gained from scientific
studies, we select what we believe to be the “best” path to
resolution of the patient’s condition. The question in our
minds must always be: What is the “best” pathway in this
particular surgical case?
Prior to the introduction of anesthesia the surgical experi­
ence was a decidedly unpleasant one for the patient. The
success of a surgical procedure (read: survival) was often
based on the speed at which the procedure was accomplished.
If nothing else, the introduction of anesthetic techniques
brought the ability of the surgical team to take more time in
accomplishing the procedure. The introduction of an addi­
tional medical intervention (anesthesia) on the patient brought
additional undesired effects and perioperative death.1,2 Since
the introduction of general and regional anesthesia as part of
normal surgical practice, surgical and anesthetic complication
rates have been analyzed using a variety of clinical criteria. It
is this wide variety of criteria that has led to confusion in the
medical literature and in the mind of practicing clinicians of
the actual risk attributable to anesthesia care during a surgical
intervention. Do we consider in our complication rate only
events that happened during the actual surgical procedure?
Do we only consider events attributed solely to providing
anesthesia or do we consider the contribution of surgery to
the untoward outcome?3 The time course for evaluation of
surgical and anesthetic complications remains controversial
and almost certainly is related to the nature of the surgical
procedure and type of anesthesia, if any, that was used during
surgery. The wide variety of time indices that are used in the
medical literature for the study of perioperative complications
makes comparison of studies very difficult. Definitions of the
time period for study of perioperative mortality range from
48 hours, as defined by the Joint Commission on Accreditation
of Healthcare Organizations, to 30 days, as defined by the
American College of Surgeons. Similarly, the inability to
compare clinical studies adds to the confusion in defining
† Deceased

92
CHAPTER 8 • Patient safety in plastic surgery
at a rate of 4 deaths per million surgeries for ASA category I
patients and with 554 deaths per million in ASA category IV
patients.7 The effect of medical progress on improved clinical
outcome is often difficult to detect when the incidence of
maloccurrence is infrequent. Significant changes in daily
anesthesia practice began in the mid-1980s with the introduc­
tion of the Harvard Standards of Practice I – minimal monitor­
ing. These anesthesia standards required the use of monitoring
devices to detect and prevent impending disaster during
surgery.8 The 1986 ASA standards for basic intraoperative
monitoring encourage both capnography and pulse oximetry
during conduct of anesthesia and surgery. The incidence of
accident and death rate in ASA status I and II patients was
studied before and after the adoption of the new monitoring
standards at Harvard hospitals (Table 8.2). The implementa­
tion of these standards, along with the introduction of new
monitoring techniques, has greatly reduced the incidence of
unrecognized hypoventilation and hypoxemia leading to
intraoperative complication and death.9–11
The implications of these findings for current clinical
practice in the operating room are clear. Monitoring equip­
ment for electrocardiogram, blood pressure, pulse oximetry,
capnography, inspired concentration of oxygen on anesthesia
machines, and temperature must be available in the operating
room, functioning and used in all appropriate situations. The
proper use of monitoring devices during surgery improves
safety during surgery. Nonfunctioning monitoring equipment
postpones surgery.
It is the experience gained from in-hospital surgery and
advances in medical care that have allowed the development
of outpatient surgery. Recent data show that upwards of 60%
of surgery at community hospitals in 2005 was performed
in an outpatient setting.12 It is almost certain the percentage
of patients undergoing cosmetic and reconstructive surgery
on an outpatient basis is even higher. In the mid-1970s there
were two free-standing outpatient surgery centers in the US.
There are now over 5000. The success of outpatient surgery
done outside a hospital operating room is based on the cost-
efficient ability of these centers to meet the medical needs of
the patient and the medical staff safely. It has been shown
repeatedly that outpatient surgery can be performed with
a safety standard equal to or exceeding that available in an
inpatient hospital-based environment. The spectrum of set­
tings for performance of surgery continues to expand with the
development of office-based surgical facilities.13 The American
Society of Plastic Surgery through the Patient Safety commit­
tee has published an outstanding series of articles outlining
advisory principles for safety in ambulatory surgery.14 These
reports, based on the medical literature combined with the
general principles described above, set an educated guideline
for conduct of outpatient plastic surgery. A primary area of
concern for the plastic surgeon is patient selection for surgery
clinical risk to the patient from a given surgical or anesthetic
technique. For anesthetic risk we need to consider not only
cases where anesthesia is deemed the sole cause of complica­
tion and mortality but also cases where anesthesia is a signifi­
cant contributing factor of complications and mortality.
It remains extremely difficult, even with review of the
extensive body of medical literature, to predict accurately the
risk for any given patient who is about to undergo any given
surgical procedure. We can confidently claim that complica­
tions from anesthesia have been greatly reduced since the
widespread acceptance of modern anesthetic techniques.
Beecher and Todd published in 1954 that, where anesthesia
was a very important contributing factor, death occurred in
1 : 1560 surgeries.4 Today, patients want to know the current
state of the art of medical science in regard to perioperative
risk and complication. One of the most useful and popular
ways to assess risk in the surgical patient population is by the
American Society of Anesthesiologists (ASA) physical status.
This classification system was originally designed in the early
1940s and updated in 1961 (Table 8.1).
The ASA classification system has been shown to correlate
with surgical and anesthetic outcome.5 Lagasse’s study5
concluded that the incidence of anesthesia-related mortality
within 48 hours of surgery was 1 : 13 000 procedures, when
evaluating all patients coming for a surgical procedure. Of
great interest, but of little surprise to the practicing anesthe­
siologist, was that anesthesia-related deaths increased with
increasing ASA classification. Other reports dating as far back
as 1987 report anesthesia-related mortality rates at 1 : 185 000.6
The study by Buck et al.6 was performed before the wide­
spread acceptance of new technology monitoring systems
(pulse oximetry and capnography) that serve as early-warning
systems for respiratory compromise. More recent studies have
shown even better safety outcome results for patients having
surgery. A 2004 study performed in France again showed that
mortality rates increased with increasing patient ASA status,
Table 8.1  ASA classification
ASA I
Normal healthy patient without active disease
ASA II
Patient with mild systemic disease (e.g., hypertension
under medical control)
ASA III
Patient with severe systemic disease
ASA IV
Patient with severe systemic disease that is a
constant threat to life
ASA V
Patient who is moribund and is not expected to
survive without surgery
ASA VI
Patient who has been declared brain-dead for organ
donation
ASA, American Society of Anesthesiologists.
Table 8.2  Incidence of intraoperative anesthesia complications
Dates
ASA status I and
II patients (n)
Intraoperative accidents
(n)/incidence
Death (n)/incidence
1/1976–6/1985
757 000
10
1/75 700
5
1/151 400
7/1985–6/1988
244 000
1
1/244 000
0
0/244 000
Monitoring standards instituted 7/1985. ASA, American Society of Anesthesiologists.

93
Obese patients/sleep apnea patients having plastic surgery
Mallampati score may indicate potential difficulties in airway
maintenance and intubation.18 Conduct of the actual anesthetic
for patients with a history of sleep apnea and having plastic
surgery depends on many factors. Certainly the type of
surgery, the severity of airway disease, and the desires of the
patient are major components in the decision-making process.
The need for intubation or airway manipulation during
surgery should not be an automatic exclusionary criterion for
outpatient surgery in a patient with a history of sleep apnea.
Appropriately selected patients with a history of sleep apnea
who are observed and monitored for extended periods of time
after surgery may do well on an outpatient basis. Patients with
sleep apnea requiring large amounts of postoperative narcot­
ics or sedatives and those who are noted to have decreased
oxygen saturation levels on room air or inadequate ventilation
will require admission and continued monitoring in an acute
care setting. Monitoring of the sleep apnea patient after
surgery and after hospital admission includes continuous
oxygen saturation. Monitoring of oxygen saturation levels on
an every 4–6-hour basis makes no sense given the fact that
obstructive apneic events are more likely after surgery and
hypoxic brain injury may occur in a matter of minutes.
In addition, it may be unwise to attempt to complete a
surgical procedure on a patient with sleep apnea using local
anesthesia with deep levels of sedation. Commonly used
medications for sedation during surgery, including narcotics
and benzodiazepines, may exacerbate apneic episodes leading
to hypoxia and hypoventilation. Performing procedures on a
patient with sleep apnea with the patient in the prone position
and limited airway access without first securing the airway
may be particularly hazardous. It is often difficult to monitor
ventilation accurately in a nonintubated patient. New tech­
nologies to detect hypoventilation will need to be developed
to monitor ventilation accurately in nonairway-controlled
patients. Development of continuous arterial CO2 monitoring
using a noninvasive format will further improve patient
safety during surgery.19 Patients using continuous positive
airway pressure (CPAP) as a therapeutic modality for sleep
apnea should be instructed to bring the CPAP equipment to
the surgical center. The center should have personnel knowl­
edgeable in the application of CPAP devices available to assist
in the respiratory care of the patient. Similarly, patients who
use CPAP at home should use their CPAP while resting or
asleep at the hospital.
Despite careful attention to airway evaluation, clinical
experience and prospective studies have demonstrated a
relatively poor ability of the medical practitioner to predict
which patients will have a difficult airway. Upwards of 3% of
patients deemed to have “normal” airways may have difficulty
with intubation. The implications of our inability to predict
which patients will have a difficult airway include the need to
have an extensive selection of airway management tools avail­
able in the surgical setting where airway complications may
arise. In addition to the traditional array of laryngoscopes
and blades, airways, and endotracheal tubes of many sizes
comes the need for fiberoptic laryngoscopes, laryngeal mask
airways, and the personnel who can readily use these tools.
Newer technologies, including video laryngoscopes, should
be available to those trained in these techniques. It is not
a question of how much equipment you can purchase, but
which equipment you are skilled at using during an emer­
gency to establish an airway. Every surgical facility should
and whether or not to perform the surgery on an outpatient
basis. We have previously described the data that demonstrate
that complications increase with an increase in a patient’s
ASA status. Prospective stratification of 17 638 patients by age
found that patients over the age of 65 years were 1.4 times as
likely to have an untoward intraoperative event and twice as
likely to experience an intraoperative cardiovascular event
as patients under 65.15
Obese patients/sleep apnea patients
having plastic surgery
Multiple studies have demonstrated an increase in periop­
erative risk associated with obesity. Complications during
surgery associated with patient obesity include increased rates
of failed regional anesthesia, unplanned hospital admissions,
and an increased incidence of deep venous thrombosis.16 It is
also unreasonable to expect medical care providers to be able
to manage the obese patient physically without assistance
from other healthcare assistants. Unless an ambulatory center
is prepared to have the help the obese patient will require, the
patient should have surgery in a facility with the necessary
staff available. Setting a weight limit for patients, based on the
ability of the staff of the center to manage the patient, avoids
uncomfortable situations when the patient arrives for surgery
and the facility is unable to take care of him or her. Proper
planning at the surgical facility reduces surgical cancelations.
Obese patients have a higher incidence of sleep apnea than
patients of normal body habitus. Physical characteristics that
predispose patients to having obstructive sleep apnea include
body mass index over 35, neck circumference of 17 inches
(43 cm) in men or 16 inches (41 cm) in women, craniofacial
abnormalities affecting the airway, nasal obstruction, and
tonsil hypertrophy.17
The 2006 report by the ASA taskforce on perioperative
management of patients with obstructive sleep apnea is a
valuable reference for conduct of care of this classification of
patients.17 The severity of sleep apnea, as determined by a
formal sleep study, is seen in Table 8.3. The severity of oxygen
saturation depression during apnea events and the number of
apneic events per hour should be considered in evaluating the
patient for surgery.
Proper perioperative clinical management of patients with
sleep apnea is of critical importance. Airway management of
the obese patient, with or without sleep apnea, may be diffi­
cult. Careful airway evaluation preoperatively with notation
of mouth opening, mental–hyoid distance, submandibular
compliance, range of motion of the cervical spine, and
Table 8.3  Criteria for determining the severity of sleep apnea
after sleep study
Severity of
obstructive sleep
apnea
Adult apnea–
hypopnea index
Pediatric apnea–
hypopnea index
None
0–5
0
Mild
6–20
1–5
Moderate
21–40
6–10
Severe
>40
>10

94
CHAPTER 8 • Patient safety in plastic surgery
oxygenation and ventilation. In this closed claim study, respi­
ratory insufficiency was found to have occurred in 15% of
patients who had monitored anesthesia care versus 7% of
patients who had general anesthesia. Other factors in this
group, such as patient age and ASA classification, may have
contributed to the findings. Randomized studies comparing
anesthesia technique for a given surgical procedure must be
performed before declaring a winner in the category of anes­
thesia technique for patient safety. Very large patient popula­
tions will need to be evaluated so that appropriate conclusions
can be drawn.
Some anesthesia techniques used during surgery appear
to have been poorly evaluated for possible complications.
Epidural anesthesia for patients undergoing liposuction
appears to expose the patient to large doses of local anesthet­
ics when used in both the delivery of epidural anesthesia
and as a component of the tumescent solution. Vasodilation
by regional anesthetic blockade of the sympathetic nervous
system seems to conflict with the application of dilute solu­
tions of epinephrine for vasoconstriction during liposuction.
Again, heavy sedation of a patient in the prone position with
a high dermatome level of regional anesthetic seems unwise
for patients undergoing liposuction because of concerns with
airway compromise and respiratory insufficiency. Despite
these considerations, numerous publications have supported
regional anesthesia use in this setting. A well-thought-out
anesthetic plan that is coordinated with the surgeon and
operating room staff will add to patient safety.
Advances in medical technology and medical practice
have allowed the development of outpatient surgery to be
performed in both a free-standing surgical center and in the
medical office-based surgery setting. The American Society
of Plastic Surgery commissioned a taskforce on patient safety
in office-based surgical facilities and published a taskforce
statement.28 This taskforce statement provides conservative
judgments on the nature of surgical procedures appropriate
for the office-based setting and the appropriate magnitude of
these same surgeries. Of particular interest to the practicing
physician was the recommendation for limiting the volume
of liposuction to a total of 5000 cc of total aspirate volume (fat
and fluid). A large study looking at the clinical outcome of
631 large-volume liposuction patients showed a high degree
of safety and extremely low complication rates with much
larger total aspirate volumes.29 Our current clinical policy
limits aspirate volume to 5000 cc of supernatant fat in the
outpatient setting and allows aspiration of an additional
1000 cc of fat for patients admitted to the hospital after
surgery for continued monitoring. The medical literature
provides very little basis for the taskforce recommendations
and the medical literature and clinical experience suggest that
larger aspirate volumes may be safely performed at a single
operation. The physiologic injury of liposuction depends on
the surgical technique employed and the body surface area
of the patient. Removing 5000 cc of fat from a 100-lb (45-kg)
patient will have very different physiologic consequences
than the same type of surgery performed on a much larger
patient.
Recommendations for limits on liposuction aspiration
should be based on appropriate medical and physiologic
considerations. Suggestions have been made to limit the dura­
tion of a plastic surgery procedure as a method of establishing
safe medical practice. Perioperative clinical risk increases
be capable of performing a surgical airway (tracheostomy) in
the rare case of failed airway management.
Review of large databases evaluating the safety of surgery
has shown that surgery and anesthesia are very safe. The risk
of anesthesia as the cause of death in ASA I and ASA II category
patients is in the range of 1 : 150 000–1 : 300 000 patients.20,21
Therefore, it should be no surprise when medical publications
are presented with a small series of patients undergoing
outpatient surgery in an office-based surgery center that the
reported complication and death rates are very low.22 In a
study on office-based surgery, 84.3% of patients were ASA
class I, 15.6% ASA II, and only 0.1% ASA class III. It would
require a very large data collection of ASA I and II patients to
provide evidence of increased risk or an improved outcome
in a particular surgical setting or using a specific anesthesia
technique in this subset of patients.
Similar publications have documented the highest levels of
safety in the office surgery environment using general anes­
thesia. Hoefflin et al. published a series of 23 000 consecutive
surgical patients over an 18-year period. The advantages of
general anesthesia with airway control during surgery are
also presented.23 Again, given the relatively low incidence of
complications in this patient population and the small number
of patients studied, it will be difficult to show statistically
significant change in clinical complication rates. The American
Association for Accreditation of Ambulatory Surgery Facili­
ties study of 400 675 patients concluded that patient safety in
accredited office-based surgical facilities was equal to or
exceeded the safety level of surgery in a hospital.24 As these
articles propose, there are tangible benefits to office-based
surgery, including cost containment, convenience, and ease of
scheduling. There is little doubt that patients prefer the
quieter, gentler ambience of the office/outpatient surgery
center as compared to a busy hospital environment. The
office-based surgery/outpatient surgical environment can
provide a superb surgical environment for patient, physician,
and staff as long as the quality of care equals or exceeds that
of the full service hospital in all regards.
Intraoperative management of the
plastic surgery patient
Both the medical literature and nonpeer-reviewed publica­
tions extol the virtues of a variety of anesthesia techniques for
plastic surgery, in particular aesthetic surgery. The general
public would like to believe that a less invasive and seemingly
simpler anesthesia technique will be safer. Physicians who are
not knowledgeable of the medical literature may contribute
to this misconception. As we have seen in the case of patients
with sleep apnea, local anesthesia with deep levels of sedation
may not be an appropriate anesthetic choice and may put the
patient at substantial risk of airway compromise. Both local
anesthesia and general anesthesia produce a similar incidence
of complications in patients having oral surgery on an outpa­
tient basis.25,26 The 2006 closed claims analysis from the ASA
Closed Claims database demonstrated that, relative to the
incidence of the anesthesia technique, death during monitored
anesthesia care and general anesthesia was twice as common
as in patients undergoing a regional anesthetic.27 The primary
complication leading to death in this study was inadequate

95
Deep venous thrombosis/pulmonary emboli in the liposuction patient
of coagulopathic disease, venous thrombosis or pulmonary
embolism will aid in developing appropriate perioperative
strategy for reducing the risk of thrombotic events during
and after surgery.35 The use of prophylactic therapy for
prevention of venous thromboembolism during surgery has
been well established in the medical literature.36 However,
determining an appropriate therapeutic program for venous
thromboembolism prevention remains confusing for many
surgical practitioners, especially when the surgical procedure
is deemed “minor”, the duration of surgery is deemed short,
and the patient is discharged home after recovery from
surgery and anesthesia.
Nonpharmacologic therapy (compressive hose and inter­
mittent pneumatic compression of the foot/leg) may reduce
the risk of deep venous thrombosis (DVT) by up to 60%.35
Pharmacologic therapies for prevention of perioperative
DVT has been shown to be more effective than mechani­
cal therapies alone but increases the risk of major bleeding
complications from surgery. The use of both mechanical and
pharmacologic therapy for prevention of perioperative DVT
has not been shown to add additional protective benefit
over pharmacologic therapy alone.35 Combined use of both
compressive hose and pneumatic compressive devices has
not been shown to reduce the incidence of DVT over com­
pressive devices used alone. Elastic stockings causing skin
complications in some patients are of concern. The duration
of use of pharmacologic therapy for the prevention of DVT
will be based on specific patient needs. The use of an inferior
vena-caval filter as a primary prophylaxis modality is gener­
ally not recommended but may be appropriate for patients
having a pulmonary embolism in the postoperative period.
The primary concern with chemoprophylaxis for venous
thromboembolism prevention is postoperative bleeding,
particularly after facial cosmetic surgery, surgery that may
affect patency of the airway, and liposuction where large
areas of tissue have been disrupted and blood collection
may be extensive. As a result of these concerns, prophylactic
therapy for ambulatory plastic surgery has focused on the
use of graduated compression stockings (compressive hose)
and the use of intermittent pneumatic compression devices
fitted for the foot/leg. The use of these techniques has been
shown to reduce the incidence of venous thromboembolus.37 It
remains to be demonstrated whether these nonpharmacologic
techniques prevent pulmonary embolism or death following
outpatient plastic surgery. Compressive hose must be prop­
erly fitted for them to be effective, and ill-fitted stockings may
lead to venous occlusion or arterial compromise of the lower
extremity.
The use of intermittent pneumatic compressive devices for
the leg or foot increases venous flow and is thought to reduce
pooling of blood in the veins. Once again, proper fitting of the
device is mandatory and use of the pneumatic compressive
device should start before beginning anesthesia and continue
through the recovery period in the postanesthesia care unit.
The development of venous thromboembolism may extend
well into the postoperative period following discharge from
the medical care facility. In selected cases it may be wise
to continue mechanical prophylaxis at home, after discharge
from surgery, for the high-risk patient. Patients who have
undergone circumferential liposuction of the thigh or calf,
where the venous flow of the lower extremity may be compro­
mised, may benefit from extending the duration of mechanical
with longer surgical duration. Bringing the patient back to
the operating room for a second surgery also involves expos­
ing the patient to additional risk. The decision to perform
one longer surgery or two shorter surgeries involves many
factors.
The American Society of Plastic Surgery Patient Safety
Committee published Evidence-Based Patient Safety Advisory:
Liposuction in 2009.14 The use of lidocaine as a component of
the wetting solution injected into the fat prior to aspiration
has been well discussed in the medical literature. Local anes­
thetic in the wetting solution is used for two purposes. The
first is to reduce the level of additional anesthesia (general or
sedation) that is needed to complete the procedure and keep
the patient comfortable during surgery. The second purpose
is to provide postsurgical analgesia in the body areas where
surgery has been performed. Death from local anesthetic
overdose has occurred during liposuction. Mistakes have
been made in the compounding of the wetting solution
used during liposuction surgery. Bottles of 2% lidocaine
have been added to the wetting solution when 1% lidocaine
was prescribed for compounding. Bupivacaine 0.5% has
been added to wetting solutions when lidocaine 0.5% was
prescribed for compounding. Catastrophic outcomes have
occurred from these errors. The compounding of wetting
solutions must be confirmed by two individuals to ensure
accuracy and prevent error. Limitation of lidocaine dosing
must be conservative because of erratic and unpredictable
serum levels of local anesthesia from any given wetting solu­
tion administration.30,31 Multiple studies have documented
that plasma lidocaine levels peak 10–12 hours after wetting
solution containing dilute concentrations of epinephrine
is injected in the adipose tissue prior to liposuction. For
patients undergoing liposuction on an outpatient basis, peak
lidocaine levels will occur after discharge from the surgical
facility. Following tumescent injection into highly vascular
areas of the body such as the neck, peak lidocaine levels
occur more rapidly (6 hours) and at higher serum levels.32 In
liposuction surgery with large volumes of tumescent injec­
tion, sources of additional local anesthetic administration,
such as laryngeal tracheal anesthetics, should be avoided by
the anesthetic provider. Epinephrine levels peak after tumes­
cent injection at about 3 hours postinjection.30 It has been
postulated that elevated epinephrine levels post tumescent
injection may contribute to renal blood flow changes, leading
to decreased urine output during larger-volume liposuction.29
Perioperative fluid management for the patient undergoing
liposuction has been a topic of great debate. Clinical studies
and clinical experience have shown that approximately 30%
of injected wetting solution is aspirated during liposuction
with 70% of the injected tumescent volume remaining in the
adipose tissue and subsequently absorbed into the central
circulation.33,34
Deep venous thrombosis/pulmonary
emboli in the liposuction patient
Risk stratification and institution of appropriate therapy for
prevention of venous thrombosis and pulmonary embolism
is a key component of perioperative medical management.
Preoperative medical evaluation of patients with a history

96
CHAPTER 8 • Patient safety in plastic surgery
Care of the liposuction patient
during surgery
Coordination of patient care during liposuction by the operat­
ing team is mandatory. Strategies for tumescent solution
dosing, fluid management, patient positioning, and mainte­
nance of the patient’s body temperature during surgery
should be planned prior to the start of the surgical procedure.
Liposuction patients frequently have large portions of their
body surface area exposed to cold operating room tempera­
tures. Maintaining body temperature for the patient during
surgery may become a complex problem for the surgical team.
Anesthetics routinely cause blood flow redistribution, antago­
nizing the body’s normal mechanisms for temperature regula­
tion. Warmed intravenous fluids and tumescent solutions for
liposuction will aid in temperature preservation. Water-based
operating table heating pads have been shown to have little
benefit for temperature preservation. Routine use of two
forced air heating blankets, one over the upper part of the
body and the second over the lower part of the body, have
almost eliminated concern over hypothermia during liposuc­
tion. Changes in body positioning during liposuction surgery
must be performed expeditiously, with reapplication of the
forced air blankets as soon as is possible to maintain body
temperature.
The most common postoperative complication after lipo­
suction is skin and body contour irregularity. Of course, the
most serious outcome after liposuction is death. Abdominal
wall and vital organ perforation has been reported to occur in
14.6% of 95 fatalities following 496 245 liposuction proce­
dures.40 Patients with previous abdominal surgery or known
to have a ventral hernia appear to be at increased risk of
abdominal wall perforation. Careful preoperative abdominal
examination will identify many patients with abdominal wall
hernias. Advanced imaging by computed tomography scan
may be necessary to help identify patients with abdominal
wall defects that could lead to severe complications after
abdominal liposuction. Meticulous surgical technique is
required to reduce the incidence of vital organ injury. Perfora­
tion of the posterior flank, leading to retroperitoneal injury,
thoracic perforation, and spinal cord injury, has been reported
during liposuction. Delay in diagnosis of an abdominal wall
perforation may lead to peritoneal spillage, necrotizing fasci­
itis, sepsis, and death.41 The only thing worse than such a
catastrophic complication is the failure to diagnose such a
condition. Physician denial that a complication has occurred
is a strong component in the pathway leading to a devastating
clinical outcome after surgery.
Complications during body contour
surgery: fat transfer
The addition of fat transfer techniques has expanded the pos­
sibilities associated with body contour surgery. Prior to the
development of fat transfer from one part of the body to
another, body contour changes focused on fat removal (lipo­
suction). The removal of fat from a donor source on the body
combined with adipose cell processing and subsequent trans­
fer to another part of the body has increased patient demand
prophylaxis. Mechanical prophylaxis is contraindicated in
patients with lower-extremity edema, a history of peripheral
vascular disease of the lower extremity, or wounds or ulcers
of the feet or legs.
Patients at high risk for venous thromboembolism include
those with a history of prior venous disease, obesity (body
mass index >30), postoperative immobility, diabetes, history
of tobacco use, history of cancer, advanced age, long dura­
tion of surgery, and the use of general anesthesia.38 This
subset of high-risk patients may benefit from a combination
of mechanical and pharmacologic prophylactic measures to
reduce the incidence of venous thromboembolism. Patients
who are thought to be hypercoagulable (e.g., protein S defi­
ciency or factor V Leiden) may also warrant both mechanical
and pharmacologic therapy for thromboprophylaxis during
outpatient ambulatory surgery.39 Pharmacologic prophylaxis
is contraindicated in patients with active bleeding, recent or
anticipated regional anesthesia (epidural or spinal), infective
endocarditis, proliferative retinopathy, and in patients with
thrombocytopenia. Patients undergoing surgery with epidu­
ral anesthetics and the use of an indwelling epidural catheter
should have the catheter removed before starting anticoagu­
lant therapy. In patients with an indwelling catheter in whom
anticoagulation therapy has been instituted, the catheter
should be removed at the low point of clinical effectiveness of
anticoagulation therapy; that is, just before the administration
of the next dose of medication. The international normalized
ratio should be <1.5 at the time of catheter removal. The use of
heparin and low-molecular-weight heparin is contraindicated
in patients with a history of heparin-induced thrombocyto­
penia. Fondaparinux may be an appropriate prophylactic
therapy for patients with heparin-induced thrombocytopenia.
Aspirin as a sole modality for venous thrombosis prophylaxis
is generally not recommended. Aspirin may be indicated in
a small subset of patients at high risk for venous thrombosis
and with specific contraindications for other mechanical and
pharmacologic therapies.
Intermittent pneumatic compression devices are routinely
used for all liposuction patients because of concern with
venous stasis, vascular endothelial injury, and/or activation
of the coagulation pathway secondary to tissue trauma during
surgery. Anticoagulation therapies started prior to or immedi­
ately following liposuction surgery pose substantial bleeding
risk to the patient. During liposuction, large areas of tissue
are disrupted during surgery and visualization of bleeding
sites may be difficult. Patients who develop pulmonary
thromboemboli in the early postoperative period and given
aggressive anticoagulant therapy have experienced a great
amount of bleeding in the body areas having liposuction.
Anticoagulated liposuction patients will experience severe
bleeding, even with aggressive compressive garment therapy
in the regions of recent surgery. Vena-caval filters have been
successfully placed in postliposuction patients experiencing
pulmonary emboli. For postliposuction patients experienc­
ing these life-threatening complications, consultation with
critical care medicine and vascular surgery specialists is
mandatory.
The development of a formal, institutional policy for pre­
vention of DVT and thromboembolism is recommended.
Compliance with institutional policy should also be moni­
tored to ensure patients are receiving appropriate DVT pro­
phylaxis therapy.

97
Complications from breast surgery
postoperative blood pressure during rhytidectomy needs to
be questioned. Thorazine® has a long half-life and a long
clinical duration of action. It has numerous undesired drug
interactions, including potentiation of narcotic analgesics, and
a variety of side effects. Given that we now have better, titrat­
able antihypertensive medications, more potent antiemetics,
and better perioperative sedative medications, Thorazine® in
the surgical setting is a drug best relegated to history.
Airway management of the patient with a postoperative
facial hematoma may be frightening. Facial and neck hema­
tomas may significantly distort the airway making direct
laryngoscopy and intubation impossible. Careful evaluation
of the patient’s airway and anatomy distortion should be
performed prior to administration of sedative medications or
induction of general anesthesia in a patient with facial or neck
hematoma. Deviation of the trachea by a neck hematoma or
swelling of the base of the tongue or pharynx can cause airway
obstruction. Traditional airway rescue techniques such as the
laryngeal mask airway may not be effective because of ana­
tomical distortions caused by the hematoma. Securing the
airway with an endotracheal tube with the patient awake and
spontaneously breathing may be the safest technique prior to
induction of general anesthesia in patients with distorted
anatomy from a postoperative hematoma. Opening a suture
line with evacuation of a small area of hematoma may relieve
pressure on the airway and restore a more normal airway
anatomy. In this clinical setting, preparations should be made
for performing a surgical airway prior to attempts at fiberoptic
or awake intubation. Preparation for an airway crisis will help
avoid a clinical disaster should airway complications develop.
Massive neck swelling may also make performance of a surgi­
cal airway or cricoid thyroidotomy difficult.
Evacuation of a small postoperative facial hematoma after
rhytidectomy may be an appropriate procedure for an office-
based surgery center or free-standing surgery center. In a case
with possible airway compromise following facial surgery, a
hospital-based operating facility may provide the greatest
level of safety for the patient. It may be necessary for the
patient to remain intubated after hematoma evacuation
because of continued swelling in the neck, pharynx, and base
of tongue. Again, preparation for rapid deterioration of the
patient’s airway is mandatory.
Complications from breast surgery
The incidence of pneumothorax following breast augmenta­
tion and breast reconstructive surgery is very low – less than
1% of cases. The incidence of a pneumothorax following
primary breast augmentation is fortunately very rare, but
must be considered in a patient with otherwise unexplained
postoperative respiratory complications. Pneumothorax after
secondary breast surgery and breast reconstruction has been
reported at a higher incidence but remains infrequent. Severe
postoperative respiratory distress after breast surgery may
require positive-pressure respiratory assistance and intuba­
tion along with needle aspiration of the chest for evacuation
of a pneumothorax. Chest tube insertion for continued man­
agement of a pneumothorax is rare, but may be required for
a persistent air leak. Keeping this potential complication in
mind will allow recognition of the disorder when it presents
itself clinically.
for the procedure. With development of the transfer technique
comes the possibility of intravascular injection of fat tissue
and adipose cells leading to complications and death. Fat
emboli as a complication of liposuction has been reported in
the medical literature. Inadvertent intravascular injection of
fat tissue has been reported during fat transfer to the but­
tocks.42 Microembolization of fat particles and large fat glob­
ules into the pulmonary vasculature has been reported. Fat
transfer to the buttock may be performed by transfer of fat
tissue to the subcutaneous/adipose region of the buttock or
by transfer of fat tissue into the gluteal muscles of the buttock.
Intramuscular transfer of fat tissue to the deeper muscular
layers may increase the risk of intravascular injection to the
deep venous plexus underneath the muscle layers. Inadver­
tent, deep intravascular injection into the iliac vessels has also
been proposed as a mechanism for fat embolism to the lung.
Determining the appropriate depth of tissue transfer to the
buttocks may be difficult. Identifying the vascular structures
deep within the buttocks with intraoperative ultrasound to
avoid vascular injection has been proposed but remains an
untested technique. Aspiration by syringe prior to injection of
tissue may help avoid vascular injection of tissue but is
unlikely to completely eliminate a potentially life-threatening
complication. Deep needle penetration to the buttocks also
raises the possibility of sciatic nerve injury when anatomical
landmarks are distorted.
Embolization of tissue filler materials, including fat trans­
fer, following injection into the face resulting in blindness has
also been reported. It has been suggested that intravascular
injection resulting in retrograde flow and embolization of the
retinal artery is the cause of these unfortunate complications.
Again, careful surgical technique may reduce the incidence
of embolization. Careful aspiration prior to injection, and use
of small-diameter, blunt-tipped needles may reduce the inci­
dence of intravascular injection as compared to sharp, pointed
tip needles.43
Facial aesthetic surgery
Hematoma formation after facial rejuvenation surgery can
have serious consequences. Small hematomas may be treated
with conservative techniques, such as external pressure to the
affected area, or require percutaneous aspiration with a needle
and syringe. Large hematomas, expanding hematomas, or
blood collections causing pressure on the patient’s airway are
more likely to require surgical intervention. Surgical studies
have identified perioperative hypertension with systolic
blood pressure greater than 150 mmHg and diastolic blood
pressure greater than 90 mmHg as a prime marker for post­
operative hematoma formation after facial surgery. Recom­
mendations for aggressive blood pressure control surrounding
the time of planned rhytidectomy have been proposed by
many authors. Whether preoperative prescription of antihy­
pertensive medications such as clonidine should be used to
reduce the incidence of postoperative facial hematoma, as
opposed to intraoperative titration of antihypertensive medi­
cations, is as yet unanswered. As with any such critical ques­
tion, randomized studies will need to be performed. The
administration of oral or intramuscular medications around
the time of surgery should be carefully evaluated. The peri­
operative use of Thorazine® to control intraoperative and

98
CHAPTER 8 • Patient safety in plastic surgery
technique and improving clinical outcome through better
surgery. Most physicians strive to improve clinical outcome
by advancing their knowledge of the scientific literature that
is the basis of medical practice. However, poor patient outcome
during surgery is often due to failure of the medical system
to meet the needs of the patient. Medical facilities should have
mechanisms in place to ensure that patients receive the correct
surgical procedure. Following this concept, the Joint Commis­
sion under the National Patient Safety Goals has adopted the
Universal Protocol for Preventing Wrong Site, Wrong Proce­
dure and Wrong Person Surgery.45 The Universal Protocol is
founded on the concept that performing the wrong surgery
must be prevented and that aggressive strategies must be
implemented for successfully protecting the patient. Verifica­
tion of patient identity is performed multiple times by multiple
individuals involved in the medical care and surgical care
process. This verification process begins with preoperative
patient verification and confirmation of medical conditions.
This preoperative verification includes patient identity
confirmed verbally with the patient and with checking the
patient’s arm band. Confirmation of the surgical site and
surgical procedure along with proper surgical site marking by
the physician or designee is performed. Verification of the
surgical permit, appropriate history, and physical examina­
tion documentation along with laboratory studies and plans
for blood transfusion are included in this preoperative review.
Which members of the surgical team should be allowed to
perform surgical site marking remains highly controversial in
the medical community. These debates will continue, but it is
safe to state that the surgical site must be marked preopera­
tively, meeting the National Patient Safety Goals and good
perioperative medical judgment.
The World Health Organization has adopted a surgical
patient safety checklist to reduce the incidence of medical
errors.46 This checklist includes procedures to be performed
prior to the induction of anesthesia (Boxes 8.1 & 8.2).
Performance of the “time-out” procedure ensures that the
correct patient is about to undergo the correct surgery on the
correct surgical site. The “time-out” procedure requires that
the entire operative team focus on the identification process
and participate in performing the “time-out.” The operative
team includes the surgeon and surgical assistants, the anes­
thesia care provider, the nurse in the operating room, the
surgical technician, and other individuals in the operating
room who will be participating in the surgical procedure (i.e.,
radiology personnel). When more than one procedure is to
Fire in the operating room
The development of thermal injury secondary to a fire in the
surgical field can lead to devastating consequences. As many
as 200 operating room fires involving patients undergoing
surgery may be occurring every year. The concept of the fire
triad helps to explain the development of a fire during surgery.
The fire triad comprises: (1) an oxidizer, which in an operating
room setting includes oxygen and nitrous oxide; (2) an igni­
tion source, which may be an electrocautery-type device or
laser; and (3) a fuel source such as drapes, gauze, prepping
solutions, or a patient’s body tissue. Prevention of fires in the
operating room during surgery starts with physician and staff
awareness of the possible contributing factors to an operating
room fire. The ASA Taskforce on Operating Room Fires has
developed specific recommendations to reduce the incidence
of operating room fires.44 Oxygen-enriched environments
readily promote ignition of a combustible material. The
contour of the surgical drapes around the patient’s face may
allow oxygen to accumulate and promote combustion. Allow­
ing free air flow around a surgical area may reduce the inci­
dence of ignition of combustible material. Minimizing the
delivery of supplemental oxygen (nasal cannula or face mask)
to the surgical region may reduce the incidence of combus­
tion. For patients receiving supplemental oxygen via nasal
cannula or face mask while undergoing facial surgery, mini­
mizing the oxygen concentration in the surgical field is
mandatory. This may be achieved by using the lowest possible
oxygen flow to the patient that produces satisfactory oxygen
saturation levels, and by suctioning in the surgical field to
reduce oxygen accumulation in the surgical area. It may be
necessary to secure the airway for high concentration of
oxygen delivery to the patient to reduce the risk of fire of the
face or airway.
Surgical sponges should be moistened when used near an
ignition source. Flammable skin-prepping solutions should be
allowed to dry before draping to reduce the risk of accumula­
tion of potentially flammable gases. The lowest possible
cautery and laser settings should be used to limit ignition
potential. Treatment of a facial or airway fire includes stop­
ping the flow of delivered gases to the patient, removal of
burning material as soon as possible, including an enflamed
endotracheal tube if it has caught on fire, and extinguishing
flames with saline as rapidly as possible. Concerns with
airway thermal injury must be thoroughly evaluated with
laryngoscopy and bronchoscopy if necessary. Airway man­
agement after facial fire or airway thermal injury will require
additional medical consultation and intensive care unit moni­
toring of the patient.
Protocol-based systems for reducing
wrong patient and wrong-sided surgery
Much of this chapter has discussed techniques for improving
patient safety during surgery based on our knowledge of the
pharmacology and physiology of the surgery being per­
formed. Other portions of the chapter have sought to educate
the medical practitioner through review of the medical litera­
ture of surgical and anesthetic risk. Other portions of this
textbook seek to educate the medical practitioner on surgical
BOX 8.1  Confirm the following information with the patient prior to
induction of anesthesia
Patient identity
Site marking by surgeon
Surgical consent
Current history and physical
Allergy band
Special needs or instrumentation, i.e., continuous positive airway
pressure machine for after surgery for a patient with sleep apnea

99
The sociology of the plastic surgery operating room
as expected. Attempts at regulation of the surgical environ­
ment, with accreditation of surgical facilities, have certainly
increased the quality of documentation during surgery, but
have they improved outcome? Accreditation of a surgical
facility includes reviewing processes and systems but may
not actually observe the performance of a single surgery.
The accreditation process taking 1, 2, or 3 days evaluates
a surgical facility at a point in time. The actual conduct of
that facility going forward may not come under scrutiny for
another 1–3 years. Compromise in standards by a physician
or by the surgical facility may occur slowly and yet soon
be so substandard as to put the patient at unnecessary risk.
Ultimately, the decision to practice plastic surgery safely will
rest with the physician.
The standard of clinical practice in a surgery center or
office-based surgical facility must meet or exceed that of an
accredited hospital. A series of 10 core principles was pub­
lished in 2004 advocating the fundamentals of practice for
aesthetic surgery.47 These same principles are as valid today
as when they were first published and should apply to all
practitioners and all surgical specialists. Patients should be
selected for surgery based on the established criteria set by
the ASA classification system. Physicians performing office-
based surgery must have admitting privileges at a nearby
hospital and a transfer agreement with that hospital facilitat­
ing patient transfer and admission when needed. Physicians
performing office-based surgery must show competency by
maintaining surgical privileges at an accredited licensed
hospital or ambulatory surgery center for the same procedures
being performed in the office setting. Serious peer review of
surgical performance and medical management in an outpa­
tient surgical center or a private surgical facility should be
mandatory for the benefit of the patient. Is it appropriate that
a physician who is denied privileges at a hospital to perform
surgery has the right to open a private facility without peer
review and perform those same procedures? Should a pri­
vately owned surgical facility function as a hiding place for a
physician to escape peer review? The same rules that apply
to a practicing surgeon should also apply to the practicing
anesthesiologist. No medical practitioner should be above
answering to his or her medical peers during a clinical review.
We must begin to question the conduct of clinical practice in
the operating room during surgery. A patient can reasonably
expect that the focus of the surgical team will be dedicated
to performing their jobs to deliver the best possible surgical
outcome. Surgical team members (nurses, scrub technicians)
who have gone through great effort to maximize the quality
and safety of the surgical outcome are not interchangeable
with other individuals who have not familiarized themselves
with the medical facts of the case. The risk for error increases
and the quality of care for the patient decreases when surgi­
cal team members change during surgery. No matter how
complete the medical “handoff” from one team member to
another, no handoff can be as complete as having been in the
case from the beginning. Having several different operating
room nurses and surgical technicians during a single surgery
increases the risk of error and should be discouraged. Conti­
nuity of care by the anesthesia care team also improves patient
safety. Plastic surgery cases may take a long time and some
change in personnel may be necessary during the procedure,
but should be minimized. It should not need to be said,
but surgery should be performed by the attending surgeon
be performed on the same patient by different surgeons, a
“time-out” is performed before the start of each portion of the
surgery. The “time-out” procedure must confirm:
1. The patient’s identity is correct.
2. The surgical site is correct.
3. The surgical procedure that is planned.
4. Surgical consent is complete and accurate.
5. The surgical site has been properly marked and is
visible in the surgical field.
6. Imaging studies and implantable devices are available
(if indicated).
7. Prophylactic antibiotics (if indicated) have been given.
8. Deep venous thrombosis prophylaxis has been
instituted (if indicated).
9. Implementation of aseptic technique has been reviewed.
10. Procedure duration and anticipated blood loss are
checked.
11. Other areas of concern during surgery by any member
of the surgical team are noted.
After completion of the procedure a postsurgical evaluation
is performed by the surgical team. This portion of the surgical
safety checklist includes:
1. Sponge and needle counts are correct.
2. Review of the surgical consent confirms completion of
all planned procedures.
3. Pathology specimens will be properly sent to the lab.
4. Plans for postanesthesia recovery have been made and
personnel have been notified of the patient’s
forthcoming arrival.
All team members must be full participants in the “time-out”
procedure. Failure to perform these well-established proce­
dures puts the patient at risk for grave error and brings into
question the quality of care being provided to the patient.
The sociology of the plastic surgery
operating room
The American Society of Plastic Surgery and the American
Society for Aesthetic Plastic Surgery have promoted a “patient-
first” initiative in advocating for safety in the operating room.
Advances in surgical technique and perioperative medical
management have allowed improved clinical outcomes. As
much as our medical knowledge increases, we sense a great
disappointment when the clinical outcome is not as good
BOX 8.2  Confirm with anesthesia care provider
Anesthesia safety check completed
Pulse oximeter in place and functioning
Anticipated difficult airway or pulmonary aspiration risk
Risk of blood loss greater than 500 cc in an adult or greater than
7 mL/kg in a child
Need for blood typing and crossmatch
Special anesthesia equipment needs

100
CHAPTER 8 • Patient safety in plastic surgery
and designated assistants and not by unlicensed minimally
trained individuals deemed “qualified” by the surgeon. A
lack of operating room oversight can lead to poor practice
quality that may not be detected by a chart and documenta­
tion review by a certifying agency.
Best of intentions, not the best
of results
Despite the best of intentions on the part of physicians and the
healthcare system, errors occurring during hospitalization
may cause upwards of 98 000 deaths per year and over 1
million significant injuries. Recent publication of a study
showing a failure of new hospital policy and procedures to
improve patient safety in a hospital setting is disappointing.
Chart review of 2341 randomly selected hospital admissions
from 10 randomly selected hospitals between 2002 and 2007
was performed.48 In this review, patients were deemed to have
been harmed during their hospitalization in 588 instances,
about 1 in 4 patients. In 50 of these cases the harm was consid­
ered to have been life-threatening, 17 cases resulted in perma­
nent injury and 14 deaths were deemed in part due to medical
error. Despite implementation during the study period of poli­
cies and procedures to reduce medical error, the error rate
remained steady at 25 harms per 100 hospital admissions.49
5. Lagasse RS. Anesthesia safety: model or myth? A review of the
published literature and analysis of current original data.
Anesthesiology. 2002;97:1609–1617. This paper presents an excellent
review of literature comparing a variety of indicators that measure
patient safety during anesthesia. Different measurement techniques
illustrate several perspectives on the current state of surgical safety. By
understanding the literature we may be better able to advise patients of
the relative risk of their planned surgical procedure.
8. Eichhorn JH. Prevention of intraoperative anesthesia accidents and
related severe injury through safety monitoring. Anesthesiology.
1989;70:572–577. This paper describes the statistics behind the claims of
improved safety during anesthesia with the use of state-of-the-art
monitoring techniques. The Harvard experience before and after the
introduction of monitoring standards.
13. Iverson RE, the ASPS Task Force on Patient Safety in Office-based
Surgery Facilities. Patient safety in office-based surgery facilities:
procedures in the office-based surgery setting. Plast Reconstr Surg.
2002;110:1337–1344. This paper presents the safe performance of
office-based surgery. The ASPS Task Force report on patient safety.
Guidelines and thought processes for safe outpatient surgery including
recommendations for intraoperative management of the patient and the
need for office-based surgical facility accreditation.
17. Gross JB, Bachenberg KL, Benumof JL, et al. Practice guidelines for
the perioperative management of patients with obstructive sleep
apnea: a report by the American Society of Anesthesiologists Task
Force on Perioperative Management of patients with obstructive
sleep apnea. Anesthesiology. 2006;104:1081–1093. This paper remains
a cornerstone for the perioperative management of patients with a history
of sleep apnea and who are having anesthesia and surgery. An evidence-
based set of recommendations for perioperative management of the sleep
apnea patient. A more specific set of recommendations published in the
literature will be helpful after additional clinical experience with this
subset of patients.
22. Bitar G, Mullis W, Jacobs W, et al. Safety and efficacy of office-
based surgery with monitored anesthesia care/sedation in 4778
consecutive plastic surgery procedures. Plast Reconstr Surg.
2003;111:150–156. This paper describes a large series of patients
undergoing plastic surgery using monitored anesthesia care as the
anesthetic of choice. However, the low incidence of complications in this
patient subset does not allow the paper to conclude that one anesthetic
technique is safer than another technique.
23. Hoefflin SM, Bornstein JB, Gordon M. General anesthesia in an
office-based plastic surgical facility: a report on more than 23 000
consecutive office-based procedures under general anesthesia with
no significant anesthetic complications. Plast Reconstr Surg.
2001;107:243–251. This paper describes a very large clinical experience
of patients undergoing plastic surgery using general anesthesia in an
office-based setting. Again, because of the low incidence of complications
in this patient population, no conclusion as to the superiority of this
technique compared to other techniques can be made.
29. Commons GW, Halperin BD, Chang CC. Large volume
liposuction: a review of 631 consecutive cases over 12 years. Plast
Reconstr Surg. 2001;108:1753–1763. This paper describes a series of
patients who underwent large-volume liposuction and the associated very
low complication rate associated with the procedure. A description of the
surgical technique and the pharmacology and physiology behind the
medical approach to the patient is presented. A demonstration that larger
volumes of fat aspirate may be performed with a high degree of patient
safety.
34. Kenkel JM, Lipschitz AH, Luby M, et al. Hemodynamic
physiology and thermoregulation in liposuction. Plast Reconstr
Surg. 2004;114:503–513. This paper presents the results of invasive
hemodynamic monitoring studies performed during liposuction. The
results are particularly helpful for understanding the physiologic effects
of the wetting solution used for liposuction. Understanding the
physiologic changes during surgery is mandatory for the proper
management of the liposuction patient. The importance of maintaining
normothermia during liposuction is also described and the factors
leading to intraoperative heat loss are outlined for the benefit of the
clinician.
44. Caplan RA, Barker SJ, Connis RT, et al. Practice advisory for the
prevention and management of operating room fires.
Anesthesiology. 2008;108:786–801. This paper is the most comprehensive
publication on the subject of fire in the operating room during surgery.
An explanation of the causation of operating room fire helps the
practitioner to understand the recommendations made to reduce the
incidence of this terrible complication. Failure to follow the standards put
forward in this paper puts the patient at additional risk of an
intraoperative ignition event.
48. Landrigan CP. Temporal trends in rates of patient harm resulting
from medical care. N Engl J Med. 2010;363:2124–2134.
Access the complete reference list online at

100.e1
References
References
1. Beecher HK. Deaths during anesthesia. Lancet. 1954;267:922–923.
2. Dornette WH, Orth OS. Death in the operating room. Curr Res
Anesth Analg. 1956;35:545–569.
3. Dripps RD, Lamont A, Eckenhoff JE. The role of anesthesia in
surgical mortality. JAMA. 1961;178:261–266.
4. Beecher HK, Todd DP. A study of deaths associated with
anesthesia and surgery. Ann Surg. 1954;140:2–34.
5. Lagasse RS. Anesthesia safety: model or myth? A review of the
published literature and analysis of current original data.
Anesthesiology. 2002;97:1609–1617. This paper presents an excellent
review of literature comparing a variety of indicators that measure
patient safety during anesthesia. Different measurement techniques
illustrate several perspectives on the current state of surgical safety. By
understanding the literature we may be better able to advise patients of
the relative risk of their planned surgical procedure.
6. Buck N, Devlin HB, Lunn JL. Report of a Confidential Enquiry into
Perioperative Death. London: The King’s Fund Publishing House;
1987.
7. Lienhart A, Auroy Y, Pequignot F, et al. Preliminary results from
the SFAR-iNSERM inquiry on anaesthesia related deaths in France.
Mortality rates have fallen ten-fold over the past two decades. Bull
Acad Natl Med. 2004;188:1429–1437.
8. Eichhorn JH. Prevention of intraoperative anesthesia accidents and
related severe injury through safety monitoring. Anesthesiology.
1989;70:572–577. This paper describes the statistics behind the claims of
improved safety during anesthesia with the use of state-of-the-art
monitoring techniques. The Harvard experience before and after the
introduction of monitoring standards.
9. Caplan RA, Posner K, Ward RW, et al. Respiratory mishaps:
principal areas of risk and implications for anesthetic care
(abstract). Anesthesiology. 1987;67:A469.
10. Caplan RA, Posner K, Ward RW, et al. Unexpected cardiac arrest
during spinal anesthesia; a closed claims analysis of predisposing
factors. Anesthesiology. 1988;68:5–11.
11. Whitcher C, Ream AK, Parsons D, et al. Anesthetic mishaps and
the cost of monitoring; a proposed standard for monitoring
equipment. J Clin Monit. 1988;4:5–15.
12. National Center for Health Statistics. Health, United States 2007.
Trends in the Health of America. Hyattsville, MD: US Government
Printing Office; 2007.
13. Iverson RE, the ASPS Task Force on Patient Safety in Office-based
Surgery Facilities. Patient safety in office-based surgery facilities:
procedures in the office-based surgery setting. Plast Reconstr Surg.
2002;110:1337–1344. This paper presents the safe performance of
office-based surgery. The ASPS Task Force report on patient safety.
Guidelines and thought processes for safe outpatient surgery including
recommendations for intraoperative management of the patient and the
need for office-based surgical facility accreditation.
14. Haeck PC, Swanson JA, Iverson RE, et al. Patient safety outcomes
article evidence-based patient safety advisory: liposuction. Plast
Reconstr Surg. 2009;124:28S–44S.
15. Chung F, Mezei G, Tong D. Pre-existing medical conditions as
predictors of adverse events in day case surgery. Br J Anaesth.
1999;83:262–270.
16. Mandal A, Imran D, Mckinnell T, et al. Unplanned admissions
following ambulatory plastic surgery: A retrospective study. Ann R
Coll Surg Engl. 2005;87:466–468.
17. Gross JB, Bachenberg KL, Benumof JL, et al. Practice guidelines for
the perioperative management of patients with obstructive sleep
apnea: a report by the American Society of Anesthesiologists Task
Force on Perioperative Management of patients with obstructive
sleep apnea. Anesthesiology. 2006;104:1081–1093. This paper remains
a cornerstone for the perioperative management of patients with a history
of sleep apnea and who are having anesthesia and surgery. An evidence-
based set of recommendations for perioperative management of the sleep
apnea patient. A more specific set of recommendations published in the
literature will be helpful after additional clinical experience with this
subset of patients.
18. Mallampati SR, Gatt SP, Gugino L, et al. A clinical sign to predict
difficult tracheal intubation: A prospective study. Can Anaesth Soc
J. 1985;32:429–434.
19. Hillman DR, Loadsman JA, Platt P, et al. Obstructive sleep apnea
and anaesthesia. Sleep Med Rev. 2004;8:459–471.
20. Eichhorn JH, Hassan ZU. Anesthesia, perioperative mortality and
predictors of adverse outcomes. In: Lobato EB, Gravenstein N,
Kirby RR, eds. Complications in Anesthesiology. Philadelphia:
Lippincott, Williams & Wilkins; 2008.
21. Committee on Quality of Health Care in America of the Institute
of Medicine. To Err is Human: Building a Safer Healthcare System.
Washington, DC: National Academy Press; 1999:32.
22. Bitar G, Mullis W, Jacobs W, et al. Safety and efficacy of office-
based surgery with monitored anesthesia care/sedation in 4778
consecutive plastic surgery procedures. Plast Reconstr Surg.
2003;111:150–156. This paper describes a large series of patients
undergoing plastic surgery using monitored anesthesia care as the
anesthetic of choice. However, the low incidence of complications in this
patient subset does not allow the paper to conclude that one anesthetic
technique is safer than another technique.
23. Hoefflin SM, Bornstein JB, Gordon M. General anesthesia in an
office-based plastic surgical facility: a report on more than 23 000
consecutive office-based procedures under general anesthesia with
no significant anesthetic complications. Plast Reconstr Surg.
2001;107:243–251. This paper describes a very large clinical experience
of patients undergoing plastic surgery using general anesthesia in an
office-based setting. Again, because of the low incidence of complications
in this patient population, no conclusion as to the superiority of this
technique compared to other techniques can be made.
24. Morello DC, Colon GA, Fredricks S, et al. Patient safety in
accredited office surgical facilities. Plast Reconstr Surg.
1997;99:1496–1500.
25. Sarego M, Watcha MF, White PF. The changing role of monitored
anesthesia care in the ambulatory setting. Anesth Analg.
1997;85:1020–1036.
26. Muir VM, Leonard M, Haddaway E. Morbidity following dental
extraction: a comparative survey of local anesthesia and general
anesthesia. Anaesthesia. 1976;31:171–180.
27. Bhananker S, Posner KL, Cheney FW, et al. Injury and liability
associated with monitored anesthesia care: a close claims analysis.
Anesthesiology. 2006;104:228–234.
28. Iverson RE, the ASPS Task Force on Patient Safety in Office-Based
Surgery Facilities. Patient safety in office-based surgery facilities: I.
Procedures in the office-based surgery setting. Plast Reconstr Surg.
2002;110:337–1344.
29. Commons GW, Halperin BD, Chang CC. Large volume
liposuction: a review of 631 consecutive cases over 12 years. Plast
Reconstr Surg. 2001;108:1753–1763. This paper describes a series of
patients who underwent large-volume liposuction and the associated very
low complication rate associated with the procedure. A description of the
surgical technique and the pharmacology and physiology behind the
medical approach to the patient is presented. A demonstration that larger
volumes of fat aspirate may be performed with a high degree of patient
safety.
30. Burk RW III, Guzman-Stein G, Vasconez LO. Lidocaine and
epinephrine levels in tumescent technique liposuction. Plast
Reconstr Surg. 1996;97:1379–1384.
31. Nordstrom H, Stange K. Plasma lidocaine levels and risks after
liposuction with tumescent anaesthesia. Acta Anaesthesiol Scand.
2005;49:1487–1490.
32. Rubin JP, Bierman C, Rosnow C, et al. Rapid absorption of
tumescent lidocaine above the clavicles: a prospective clinical
study. Plast Reconstr Surg. 2005;115:1744–1751.
33. Trott SA, Beran SJ, Rochrich R, et al. Safety considerations and
fluid resuscitation in liposuction: An analysis of 53 consecutive
patients. Plast Reconstr Surg. 1998;102:2220–2229.
34. Kenkel JM, Lipschitz AH, Luby M, et al. Hemodynamic
physiology and thermoregulation in liposuction. Plast Reconstr
Surg. 2004;114:503–513. This paper presents the results of invasive
hemodynamic monitoring studies performed during liposuction. The
results are particularly helpful for understanding the physiologic effects
of the wetting solution used for liposuction. Understanding the

100.e2
CHAPTER 8 • Patient safety in plastic surgery
physiologic changes during surgery is mandatory for the proper
management of the liposuction patient. The importance of maintaining
normothermia during liposuction is also described and the factors leading
to intraoperative heat loss are outlined for the benefit of the clinician.
35. Gould MK, Garcia DA, Samama CM. Prevention of VTE in
nonorthopedic surgical patients. Chest. 2012;141:e227S–e277S.
36. Geerts W, Pineo G, Heit J, et al. Prevention of venous
thromboembolism. Chest. 2004;126(suppl):3385–4005.
37. Manek VW. Meta-analysis of effectiveness of intermittent
pneumatic compression devices with a comparison of thigh-high
to knee-high sleeves. Am Surg. 1998;64:1050–1058.
38. Murphy RX, Peterson EA, Adkinson JM, et al. Plastic surgeon
compliance with national safety initiatives: clinical outcomes and
“never events”. Plast Reconstr Surg. 2010;126:653–656.
39. Haeck PC, Swanson JA, Schechter LS, et al. Evidence-based patient
safety advisory: blood dyscrasias. Plast Reconstr Surg. 2009;
124(suppl):82S.
40. Grazer FM, De Jong RH. Fatal outcomes from liposuction: census
survey of cosmetic surgeons. Plast Reconstr Surg. 2000;105:436–446.
41. Sharma D, Dalencourt G, Bitterly T, Benotti PN. Small intestinal
perforation and necrotizing fasciitis after abdominal liposuction.
Aesth Plast Surg. 2006;30:712–716.
42. Astarita DC, Scheinin LA, Sathyavagiswaran L. Fat transfer and
fatal macroembolization. J Forensic Sci. 2015;60:509–510.
43. Lazzeri D, Agostini T, Gigus M, et al. Blindness following cosmetic
injection of the face. Plast Reconstr Surg. 2012;129:995–1012.
44. Caplan RA, Barker SJ, Connis RT, et al. Practice advisory for the
prevention and management of operating room fires.
Anesthesiology. 2008;108:786–801. This paper is the most comprehensive
publication on the subject of fire in the operating room during surgery.
An explanation of the causation of operating room fire helps the
practitioner to understand the recommendations made to reduce the
incidence of this terrible complication. Failure to follow the standards put
forward in this paper puts the patient at additional risk of an
intraoperative ignition event.
45. Joint Commission on Accreditation of Healthcare Organizations.
Hospital Accreditation Standards. Accreditation Policies.
2010;UP.01.01.01–UP.01.03.01.
46. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist
to reduce morbidity and mortality in a global population. N Engl J
Med. 2009;360:491–499.
47. Rohrich R. Patient safety first in plastic surgery. Plast Reconstr
Surg. 2004;114:201–203.
48. Landrigan CP. Temporal trends in rates of patient harm resulting
from medical care. N Engl J Med. 2010;363:2124–2134.
49. Landrigan CP, Parry GJ, Bones CB, et al. Temporal trends in rates
of patient harm resulting from medical care. N Engl J Med.
2010;363:2124–2134.

9 
Anesthesia and pain management in
plastic surgery
Paul N. Afrooz and Franklyn P. Cladis
SYNOPSIS
■ Inadequate pain control may decrease quality of life and delay recovery
and the return to normal activities.
■ NSAIDs are very efficacious and have a low NNT (number needed to
treat).
■ Obstructive sleep apnea (OSA) increases opioid sensitivity and appears
to increase the risk for postoperative respiratory complications.
■ Regional analgesia (epidural, paravertebral, transversus abdominis
plane block) reduces postoperative opioid requirements.
Introduction
Pain management before, during, and after any procedure is
a key component to successful outcomes in plastic surgery.
Consistent patient satisfaction hinges largely upon favorable
impressions and recollections of the surgical experience. As
such, patient satisfaction and pain management protocols
must be effective, dynamic, multimodal, and customizable.
Pain is a self-reported, complex, and subjective experience
commonly defined as an unpleasant sensory and emotional
experience due to actual or potential tissue damage.1 The
perception of pain involves both the peripheral and central
nervous system. Both spinal and supraspinal sites play a role
in the perception of pain within the central nervous system.
Pain can be generally classified into physiological and patho­
logical pain. Physiologic or nociceptive pain is acute in nature
and serves as a warning or protective function, thus promot­
ing healing and rendering it physiologically useful. In contrast,
chronic pain (e.g., neuropathic) persists beyond the period of
healing rendering it nonprotective and maladaptive; other­
wise classified as pathologic pain.
Historically, pain protocols have relied heavily on opioid-
based therapies which have several inherent drawbacks. The
etiology of pain is often multifactorial, and therefore success­
ful treatment depends on a multimodal approach. Analgesic
regimens should target the peripheral nociceptors at the site
of tissue injury, peripheral nerves supplying the surgical area,
and both spinal and supraspinal sites. This multi-targeted
strategy provides highly effective pain management while
minimizing the adverse effects of single-agent strategies.
This chapter will focus on current concepts in pain manage­
ment in plastic surgery while drawing on several themes,
including:
■ Multimodal analgesia with an emphasis on opioid
reduction
■ Neuraxial analgesia such as epidural, paravertebral, and
peripheral nerve blocks
■ Field blocks
■ Systematic extensive surgical site infiltration with long-
acting local anesthetics.
Clinical consequences of inadequate
pain relief
Despite new strategies and evolving pain management
regimens, postoperative pain remains one of the primary
concerns of patients undergoing surgery. Approximately 80%
of patients report acute pain after surgery with the majority
experiencing moderate-to-severe pain.2 The clinical manifes­
tations of inadequate pain management include myocardial
ischemia, impaired pulmonary function, ileus, thromboembo­
lism, impaired immune function, and anxiety (Table 9.1).3,4
Inadequate management of postoperative pain also
results in significant increases in healthcare costs by way of
prolonged post-anesthesia care unit stay, delayed discharge,
and readmission.5–8 Furthermore, inadequate pain control
may decrease quality of life and delay recovery and the return
to normal activities.9
The clinical impact of inadequate pain control in the periop­
erative period is significant, casting an array of effects on
multiple organ systems. The potential for postoperative wound
infections is particularly concerning in plastic surgery. Surgical
stress induces an inflammatory reaction and the release of a

102
CHAPTER 9 • Anesthesia and pain management in plastic surgery
increasing the pain threshold.13,14 Acetaminophen is available
in oral, rectal, and IV formulations, and is both analgesic and
antipyretic at therapeutic doses with a dose-dependent effi­
cacy. The maximum recommended daily dose in adults
without hepatic or renal disease is 4 grams with dose reduc­
tion recommended in patients with liver insufficiency.
IV acetaminophen produces a rapid and predictable plasma
concentration, and is recommended as a first-line agent for
the treatment of pain and fever in adults and children if oral
administration is not possible.13 The analgesic efficacy of
acetaminophen has been demonstrated in double-blind clini­
cal trials. Single dose or multiple doses of IV acetaminophen
(1 g) were significantly greater than placebo in adult patients
who had undergone dental, orthopedic, or gynecologic
surgery.
When used in therapeutic doses, acetaminophen is a rela­
tively safe drug with few and mild side effects. In comparison
to opioids, there is no effect on respiratory drive, and further­
more, it does not cause sedation, nausea and vomiting or
reduced gastrointestinal motility. In addition, the effects on
platelets and hemostasis are insignificant in patients without
a history of coagulopathy.15 There are no significant cardiovas­
cular, renal, or pulmonary side effects. The most significant
side effect is hepatotoxicity when administered in high doses,
chronic use, or when administered with alcohol or other
various hepatotoxic drugs. Very rare side effects include blood
dyscrasia (i.e. thrombocytopenia), methemoglobinemia, and
hemolytic anemia.
Nonsteroidal anti-inflammatory drugs
NSAIDs have been used effectively for the treatment of
acute and chronic pain for several decades. The primary
mechanism of action is through the inhibition of both
COX-1 and COX-2 enzymes, thereby inhibiting the synthesis
of thromboxanes and prostaglandins. NSAIDs have well-
established analgesic, antipyretic and anti-inflammatory
properties. Pharmacokinetic data and selectivity of action are
shown in Tables 9.3 and 9.4.13
number of humoral mediators along with increased levels of
cortisol during surgery. Together, these substances can have
detrimental systemic effects including hyperglycemia, catabo­
lism, impaired immune function and wound healing.4,10–12 This
physiologic and sometimes detrimental stress response to
surgery may be mitigated through adequate analgesia.
Acetaminophen, nonsteroidal
anti-inflammatory drugs, and
cyclooxygenase-2 selective inhibitors
Historically, opioids have been used successfully for pain
management in plastic surgery procedures; however, their
side-effect profile limits routine use, particularly in ambula­
tory procedures. For those procedures that do not involve
surgical manipulation of major muscle groups or osteotomies,
pain management can usually be fulfilled with non-opioid
medications such as nonsteroidal anti-inflammatory drugs
(NSAIDs), acetaminophen, and local anesthetics.13 The advent
of cyclooxygenase (COX)-2 selective inhibitors (coxibs), as
well as drugs such as gabapentin/pregabalin, clonidine, and
low-dose ketamine have added new dimensions in the arma­
mentarium of plastic surgery procedures. See Table 9.2 for
dosing.
Acetaminophen
Though less potent than NSAIDs or coxibs, acetaminophen is
the most frequently prescribed analgesic for the treatment of
acute pain. It is often preferred because it is well tolerated.
Despite the similarities to NSAIDs, the precise mechanism of
action of acetaminophen is unclear. It is believed to act via
inhibition of COX-1 and COX-2 enzymes through metabolism
by the peroxidase functions of these enzymes both centrally
and peripherally. Additional peripheral effects may be
attributable to inhibition of isoforms of COX-1, COX-2, and
COX-3 enzymes involved in prostaglandin synthesis, thereby
Table 9.1  Consequences of unrelieved pain
Cardiovascular
Increased heart rate, peripheral vascular resistance, arterial blood pressure, and myocardial contractility, resulting in
increased cardiac work, myocardial ischemia, and infarction
Pulmonary
Respiratory and abdominal muscle spasm (splinting), diaphragmatic dysfunction, decreased vital capacity, impaired
ventilation and ability to cough, atelectasis, increased ventilation/perfusion mismatch, hypoventilation, hypoxemia,
hypercarbia, increased postoperative pulmonary infection
Gastrointestinal
Increased gastrointestinal secretions and smooth muscle sphincter tone, reduced intestinal motility, ileus, nausea,
and vomiting
Renal
Oliguria, increased urinary sphincter tone, urinary retention
Coagulation
Increased platelet aggregation, venostasis, increased deep vein thrombosis, thromboembolism
Immunologic
Impaired immune function, increased infection, tumor spread or recurrence
Muscular
Muscle weakness, limitation of movement, muscle atrophy, fatigue
Psychological
Anxiety, fear, anger, depression, reduced patient satisfaction
Overall recovery
Delayed recovery, increased need for hospitalization, delayed return to normal daily living, increased healthcare
resource utilization, increased healthcare costs
Reprinted with permission from Joshi GP, Ogunnaike BO. Consequences of inadequate postoperative pain relief and chronic persistent post-operative pain. Anesthesiol
Clin North America. 2005;23:21–36