Never events in plastic surgery: An analysis of surgical burns and medical malpractice litigation.

INTRODUCTION: Burns and fires in the operating room are a known risk and their prevention has contributed to many additional safety measures. Despite these safeguards, burn injuries contribute significantly to the medical malpractice landscape. The aim of the present study is to analyze malpractice litigation related to burn and fire injuries in plastic and reconstructive surgery, identify mechanisms of injury, and develop strategies for prevention. METHODS: The Westlaw and LexisNexis databases were queried for jury verdicts and settlements in malpractice lawsuits related to burn and fire injuries that occurred during plastic surgery procedures. The Boolean terms included "burn & injury & plastic", "fire & injury & "plastic surg!"" in Westlaw, and "burn & injury & "plastic surg!"", "fire & injury & "plastic surg!"" in LexisNexis. RESULTS: A total of 46 cases met the inclusion criteria for this study. Overheated surgical instruments and cautery devices were the most common mechanisms for litigation. Plastic surgeons were defendants in 40 (87%) cases. Of the included cases, 43% were ruled in favor of the defendant, while 33% were ruled in favor of the plaintiff. Mishandling of cautery devices 6 (13%), heated surgical instruments 6 (13%), and topical acids 2 (4%) were the most common types of errors encountered. CONCLUSION: Never events causing burn injury in plastic and reconstructive surgery are ultimately caused by human error or neglect. The misuse of overheated surgical instruments and cauterizing devices should be the focus for improving patient safety and reducing the risk of medical malpractice. Forcing functions and additional safeguards should be considered to minimize the risk of costly litigation and unnecessary severe harm to patients.

Managing complications following cosmetic surgery after the COVID pandemic: A study of a year at an NHS plastic surgery unit.

BACKGROUND: The study was an analysis of patients managed by plastic surgery services at Heatherwood and Wexham Park hospitals during the calendar year 2022 for complications following cosmetic surgeries performed both internationally and within the United Kingdom. METHODS: Patients were identified via local databases and encounters and management confirmed with retrospective studies of patient electronic medical records. RESULTS: 23 patients were managed during the year 2022 for complications post cosmetic surgery. 91% (n = 21) of complications were related to breast cosmetic surgery and/or abdominoplasties. 78% (n = 18) of patients presented within the first two months following their procedure. The most common complications identified were wound dehiscence 43% (n = 10), post-operative infection 39% (n = 9) and seromas 30% (n = 7). The most common country selected for surgery by patients was Turkey with 48% (n = 11) of managed patients. 52% (n = 12) of cases were managed conservatively and 48% (n = 11) of cases required invasive procedures including surgery. 87% (n = 20) of patients were discharged with completed treatment. CONCLUSION: Cosmetic surgery and tourism are an in-demand phenomenon and appear here to stay. The stringent regulatory and legal processes in place in the UK may not be applicable abroad to the detriment of patient care. Greater effort is needed to increase public awareness to the risks involved in seeking international options and how to self-screen suitable clinics. Ongoing current national auditing may need to be expanded to understand the true impact on NHS units in dealing with the aftermath of these surgical expeditions.

[Expert characteristic of fatal outcomes related to operative interventions in aesthetic plastic surgery]. / Ekspertnaya kharakteristika letal'nykh iskhodov, svyazannykh s operativnymi vmeshatel'stvami v esteticheskoi plasticheskoi khirurgii.

THE AIM OF THE STUDY: Is to investigate fatal outcomes related to operative interventions in aesthetic plastic surgery for the period from 2010 to 2022 yrs., and to analyze the defects in health care delivery (DHCD), revealed during forensic medical examinations of fatal outcomes. The number of fatal outcomes equal 36, related to operative interventions in aesthetic plastic surgery, was analyzed. The data were collected from the expert's archival opinions (forensic medical examinations of corpse, commission forensic medical examinations based on materials of medical cases and expert opinions), and from judicial acts. The most frequent cause of death (19% of cases) was postoperative development of pulmonary artery thromboembolia, that requires further screening to assess the relationship between denoted reason and type of performed operative intervention as well as the use of anticoagulant therapy. In addition, 19% of the causes of death were related to the toxic lidocaine effects, that shows the necessity of strict control while using anaesthesia during operative interventions. During the forensic medical examination in 55.5% of cases were found the defects in health care delivery (DHCD), with an average of about two DHCD cases. Cause-effect relationship between identified drawbacks of health care delivery and fatal outcome was established in 18 (90%) of the 20 cases. Among them, the DHCD, which are extremely rare in other types of surgical specialty (health care delivery in an inappropriate place and by unqualified persons), were reliably determined in 30% of cases. The necessity of strict control by the relevant competent organizations in health care delivery for plastic surgery specialty, the need for a single system collection of information about fatal cases, associated with operative interventions in aesthetic plastic surgery, and the study of fatality structure and causes in this field were proved. The above mentioned will make it possible to develop unified approaches for the commission forensic medical examinations in this type of cases, and will also contribute to the fatal outcomes' prevention.

The Brazilian Butt Lift Remains the Deadliest Aesthetic Surgery Procedure: Are Plastic Surgeons Adjusting Their Surgical Practice to Promote Safety?

BACKGROUND: The number of Brazilian butt lift (BBL) fatalities remains high in the United States despite numerous practice advisories geared towards patient safety and reducing the incidence of fatal pulmonary fat emboli. OBJECTIVES: This study aimed to evaluate US board-certified plastic surgeons' opinions, understanding of BBL-related mortality, and current risk-reducing surgical practices for BBL procedures. METHODS: An online 18-question survey was distributed via email by the Aesthetic Surgery Education and Research Foundation to national board-certified plastic surgeon members of the The Aesthetic Society. Survey responses were collected over 21 days on the Qualtrics platform. RESULTS: The survey response rate was 10% (n = 178). Of the 77% who performed BBL procedures, 48% (n = 80) did not use ultrasound. Approximately 60% (n = 102) of all respondents disagreed with imposing regulations to require ultrasound, with the most frequent reason being that it was unnecessary with adequate surgeon experience (45%). Plastic surgeons thought that high-volume budget clinics (n = 64) and a lack of regulations imposed on individual surgeons by boards of medicine (n = 31) were the greatest contributors to BBL mortality. CONCLUSIONS: Most US plastic surgeons did not use ultrasound for BBL procedures and did not agree that ultrasound should be required, which may partially be the result of unsuccessful educational outreach for risk-reducing practices and training for ultrasound. Regulations by the boards of medicine imposed on individual surgeons, in combination with new legislation targeted at ownership of high-volume clinics, are strongly backed by surgeon respondents as measures that may improve patient safety.

Literature Review: Venous Thromboembolism Prophylaxis in Plastic Surgery.

Venous thromboembolism (VTE) is a postoperative complication experienced in all branches of surgery, including plastic surgery. Its occurrence can be lowered with adequate prophylaxis in the light of the patient's risk category and the type of surgery that will be performed. Nevertheless, thromboembolic prophylaxis is not routinely administered in plastic surgery. The prevention of VTE has gained significant attention in the past 5 years due to increased knowledge about the disease process and the alarming incidence rates. This literature review is specifically aimed at carrying out a synopsis of VTE prophylaxis trials conducted on plastic surgery patients. Antithrombotic agents have generally been avoided by plastic surgeons due to the increased risk of bleeding or hematomas; however, the prevalence of clinically important bleeding has not been found to increase with their use, as it emerges from numerous studies. VTE events can lead to increased morbidity and mortality rates, as well as a rise in healthcare costs. As it emerges from multiple studies, as a preventive measure against VTE, it is strongly advised to use mechanical prophylaxis along with low-molecular-weight heparin as the primary treatment option for plastic surgery patients who are at a greater risk. Up to date though, this practice is not commonly embraced by physicians. Preventing VTE is crucial, and measures to do so are necessary. However, there is no clear evidence to support the use of anticoagulation for plastic surgery patients, and some surgeons are hesitant to use it due to potential bleeding in extensive dissection areas.Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

How to stratify the risk of thrombosis for esthetic plastic surgery? The proposal of a new scale.

Scales to qualify the risk of thrombosis do not include all thrombogenic factors that are generated in esthetic plastic surgery. Methods: We performed a systematic review to assess the risk of thrombosis in plastic surgery. Thrombogenic factors in esthetic surgery were analyzed by a panel of experts. We proposed a scale with 2 versions. In the first version, factors were stratified according to their impact on the possible risk of thrombosis. The second version includes the same factors but in a simplified form. We evaluated the efficacy of the proposed scale by comparing it with the Caprini score; we scored the risk in 124 cases and controls. Results: Using the Caprini score, we found that 81.45% of the patients studied and 62.5% of the cases of thrombosis were observed in the low-risk group. Only 1 case of thrombosis was reported in the high-risk group. Using the stratified version of the scale, we found that the low-risk group comprised 25% of the patients, and there were no cases of thrombosis. The high-risk group included 14.51% of patients; 10 presented thrombosis (62.5%). The proposed scale was very effective in detecting both low-risk and high-risk patients undergoing esthetic surgery procedures.

Drug-induced immunosuppression in plastic and reconstructive surgery: A matched pair outcome analysis of 108 patients.

BACKGROUND: Plastic and reconstructive surgeons occasionally have to manage patients with the intake of immunosuppressive drugs while the individual risks for complications present unclear. This study aimed to analyze complication rates after surgery on patients with drug-induced immunosuppression. METHODS: Patients with a perioperative intake of immunosuppressive drugs who had undergone plastic surgery between 2007 and 2019 in our Department of Plastic, Aesthetic, Hand, and Reconstructive Surgery were analyzed retrospectively. Another cohort with the same or similar surgical procedures but without drug-induced immunosuppression was determined. A total of 54 immunosuppressed patients (IPs) were case-control matched with 54 comparable control patients (CPs). The 2 groups were compared for the outcome parameters of complication rate, revision rate, and length of hospital stay. RESULTS: Matching achieved a 100% match for surgical procedures and sex. The mean age difference within paired patients was 2.8 years (0-10 years), while the mean age was 58.1 years in all patients. A total of 44% of IP showed signs of impaired wound healing in contrast to only 19% of CP (OR 3.440; 95%CI: 1.471-8.528; p = 0.007). The median hospital stay of IP was 9 days (range 1-110 days) compared to 7 days (range 0-48 days) of CP (p = 0.102). The revision operation rate was 33% in IPs and 21% in CPs (p = 0.143). CONCLUSIONS: Patients with drug-induced immunosuppression who underwent plastic and reconstructive surgery have an increased risk for impaired wound healing in general. Additionally, our study showed a trend towards a longer hospital stay and operation revision rate. Surgeons have to consider these facts when treatment options are discussed in patients with drug-induced immunosuppression.

Evidence-Based Medicine: Systemic Perioperative Antibiotic Prophylaxis for Prevention of Surgical-Site Infections in Plastic and Reconstructive Surgery.

BACKGROUND: After nearly a decade of new data, the Evidence-Based Consensus Conference Statement from the American Association of Plastic Surgeons was updated for prophylactic systemic antibiotics to prevent surgical-site infections (SSI). Pharmacotherapeutic concepts using antimicrobial stewardship were applied for clinical interpretation and management to optimize patient outcomes and minimize resistance. METHODS: PRISMA, Cochrane, and GRADE certainty of evidence guidelines were implemented for the structure and synthesis of the review. PubMed, Embase, Cochrane Library, Web of Science, and Scopus databases were systematically and independently searched for randomized controlled trials (RCTs). The authors included patients who had plastic and reconstructive surgery and were treated with prophylactic systemic antibiotics administered perioperatively (preoperatively, intraoperatively, or postoperatively). Comparisons were made between active interventions and nonactive interventions (placebo) at different prespecified durations to determine the development of an SSI. Meta-analyses were performed. RESULTS: The authors included 138 RCTs that met eligibility criteria. RCTs consisted of 18 breast, 10 cosmetic, 21 hand/peripheral nerve, 61 pediatric/craniofacial, and 41 reconstructive studies. The authors examined bacterial data extracted from studies for patients who did or did not take prophylactic systemic antibiotics for prevention of SSI. Clinical recommendations were provided using level I evidence. CONCLUSIONS: Surgeons have long been overprescribing systemic antibiotic prophylaxis in plastic and reconstructive surgery. Evidence supports antibiotic prophylaxis to prevent SSI for specific indications and durations. Prolonged antibiotic use has not been linked to reductions in SSIs, and misuse may increase the bacterial diversity of infections. Greater efforts should focus on transitioning from practice-based to pharmacotherapeutic evidence-based medicine. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Topical Tranexamic Acid: Risks, Benefits and Novel Complications in Aesthetic Plastic Surgery.

Antifibrinolytics, particularly tranexamic acid (TXA), are agents used to reduce bleeding. TXA is a synthetic reversible competitive inhibitor to the lysine receptor found on plasminogen. By reversibly binding to this site, it leads to plasminogen being unable to bind to fibrin and so prevents fibrinolysis, this stabilizes the clot and thus prevents hemorrhage. (Pekrul in Der Anaesth 70:515-521, 2021) It can be used either intravenously or topically but has never entered mainstream use in plastic surgery. (Pekrul in Der Anaesth 70:515-521, 2021) This is most likely due to understandable fears of thromboembolic events. On the other hand, the tempting benefits are reduced bleeding (perioperatively) decreased bruising and swelling, and thus increased aesthetic, important for obvious reasons. A review of the literature was done to go deeper on this issue, examining topical use in aesthetic surgery. Clear benefit was shown in the literature, it could be postulated that it would not be unwise to consider more research on topical use of TXA in certain cases, the benefits could greatly outweigh the risks. Old fears and conceptions, unsupported by the literature at the time of writing, should not hold back further research, and the benefits shown could even potentially justify the topical use of these agents in the near future. Further studies evaluating the utility of TXA in Panniculectomy and Abdominoplasty surgery should be performed especially, since only one was found which reported no significant benefit. Minor complications were present, such as minor delayed post-auricular skin healing, temporary unilateral marginal mandibular neuropraxia and increased cumulative seroma volume. These were novel findings and could warrant further investigation as well. After performing a review of the literature, it was seen that topical TXA generally adds benefit in aesthetic plastic surgery, with no particularly significant complications. We would like to bring more attention to the issue and support more studies on TXA use. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Can Anti-inflammatory Drugs used in Plastic Surgery Procedures Increase the Risk of Hematoma?

BACKGROUND: Anti-inflammatory drugs are commonly used to lower inflammation which is linked to a variety of disorders. It acts by inhibiting cyclooxygenase-mediated prostaglandin synthesis at the molecular level. Hematoma is related with the use of anti-inflammatory medications. However, the specific link is still unknown. Thus, the main objective of the study is to find out the association of hematoma with ant-inflammatory drugs. MATERIAL AND METHODS: The relevant studies were searched in PubMed and screened based on inclusion and exclusion criteria. The quality of full-text studies was assessed using suitable Newcastle-Ottawa Scale. The overall estimate was calculated in terms of odds ratio with 95% confidence interval. The random effect model was used. The qualitative analysis of publication bias was done through funnel plot. RESULTS: The overall estimate measures [OR 1.01 (0.50, 2.06)] have shown non-significant risk of hematoma with use of anti-inflammatory drugs in plastic surgery as compared to non-anti-inflammatory drugs. The heterogeneity among studies was found to be 34%. The subgroup analysis of individual drugs was not done due to availability of a smaller number of studies. CONCLUSION: Based on available data, there is no significant risk of hematoma with use of anti-inflammatory drugs in plastic surgery. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Compulsory notification of injuries in aesthetic procedures. Impact on patient safety.

The disparity between the number of aesthetic procedures performed worldwide, and the complications described in the literature is remarkable. Doubts regarding the underreporting are reasonable and should be considered. The aim of this study is to demonstrate the scarcity of scientific publications on complications in aesthetic procedures compared to the abundance of these procedures performed worldwide. Based on this knowledge, it will be demonstrated to the health authorities the importance of compulsory notification of complications in aesthetic procedures that require medical attention so that the available data will allow their prevention. The limitation of knowledge regarding complications was demonstrated in the data collection for the preparation of the thesis "Deaths Related to Liposuction in Brazil" presented in 2018 and published in Surgical and Cosmetical Dermatology in 2020. The definition of complication in aesthetic procedures needs to be objective to prevent different and subjective interpretations. With the compulsory notification of complications in aesthetic procedures, it is intended to learn about their causes to develop guidelines for their prevention.

Practice Advisory on Gluteal Fat Grafting.

On January 31, 2018, The Multi-Society Task Force for Safety in Gluteal Fat Grafting released a practice advisory regarding gluteal fat grafting. The task force was assembled in the wake of several highly publicized patient deaths involving Brazilian Butt Lift (BBL) and produced a second practice advisory in August 2019. In 2021, The Aesthetic Surgery President commissioned a Working Group on BBL Patient Safety, charging the group to address new guidelines affecting safety and welfare of BBL patients. The "Practice Advisory on Gluteal Fat Grafting" is the first advisory developed since the working group was formed. In addition to surgical technique as a major cause of fatal complications of BBL, the working group focused on micro-economic trends of operative time and regional BBL pricing and considered fatigue and distraction in formulating the current guidelines. In Florida, the majority of BBL deaths occur at the end of the week. Such a non-normalized distribution most likely represents the result of fatigue and/or distraction, which has been linked to surgical mortality in multiple published communications. In addition, mortality is likely due to uncertainty or lack of documentation as to the correct plane of fat injection. Therefore, the newest and most compelling recommendations from these guidelines include the utilization of ultrasound-guided documentation of cannula placement prior to and during fat injection, and the limitation of 3 BBL cases as a maximum amount of total operative cases per day. The authors thank members of the task force for the insights they brought to this process.

Clinical analysis of nontuberculous mycobacterial infection after minimally invasive plastic surgery and cosmetic surgery.

OBJECTIVE: To investigate the clinical features, diagnosis, and treatment of nontuberculous mycobacterial infections after minimally invasive plastic surgery and cosmetic surgery, and to provide reference data for the management of affected patients. METHOD: We retrospectively analyzed 12 cases of nontuberculous mycobacterial infection after minimally invasive plastic surgery and cosmetic surgery in our department from January 2014 to December 2020. The case data included baseline characteristics, morbidity, chronology of patient symptoms, diagnostic results, and treatment outcomes. Disease characteristics were summarized and objectively analyzed. RESULTS: The 12 patients infected with nontuberculous mycobacteria after plastic surgery and cosmetic surgery received small incision or minimally invasive surgery. The onset time was 5-30 days after surgery, the clinical manifestations were non-specific, and ordinary antibiotics are ineffective. CONCLUSIONS: Small incisions or minimally invasive plastic surgery and cosmetic surgery have hidden dangers of nontuberculous mycobacterial infection, and the detection and diagnosis are difficult, and the treatment time is long, which requires attention.

Venous thromboembolism prophylaxis in plastic surgery: state of the art and our approach.

OBJECTIVE: The issue of prevention of thromboembolism in plastic surgery is a rather controversial subject. The actual frequency of VTE among plastic surgery patients is probably higher than we know. Although several studies have shown that chemoprophylaxis likely increases rates of re-operative hematoma by less than one percent, surgeons are strongly resistant to adopting chemoprophylaxis due to the fear of increased bleeding and its complications. MATERIALS AND METHODS: A literature review was conducted. The 2012 ACCP guidelines suggest the use of the 2005 Caprini score as the most widely used and well-validated individualized risk-stratification tool. We propose a modified 2005 Caprini score, with specific changes pertaining to plastic surgery, in which we combine a patient risk stratification model and a procedure-driven approach explicitly indicating what procedures have to be considered at high or low risk. RESULTS: The risk of venous thromboembolism in plastic surgery cannot be disregarded. However, the plastic surgery literature still lacks high-level evidence for appropriate means of VTE prophylaxis, although an increasing amount of attention has been paid to the topic. We suggest the development of an international guideline, based on plastic surgical data, using a validated risk assessment model, which combines the surgical risk with the patient-related risk. CONCLUSIONS: Determining the proper venous thromboembolism prophylaxis is a clinical decision that should be made on a patient-to-patient basis. The algorithm presented in this article is meant to simplify this complex problem and to help expedite and clarify the decision-making process.

Conceptual Paper: Abdominoplasty and Liposuction in Systemic Sclerosis.

BACKGROUND: Surgical interventions in patients with systemic sclerosis (SSc), in particular plastic procedures, might cause undesired consequences. Notably, liposuction seems to possess greater risk as adipose tissue has been shown to play an important role in treating wounds and ulcers in patients with SSc. While anticentromere antibodies were found to be correlated with vasculopathy in SSc, patients with SSc and anticentromere antibodies might be more vulnerable to surgical wound complications following liposuction. A 46-year-old female patient, who had been diagnosed with SSc at the age of 31 years, had antinuclear as well as anticentromere antibodies. She underwent abdominoplasty with liposuction and developed severe skin necrosis of the abdomen following the procedure and at the site of liposuction. The correlation with anticentromere and the role of liposuction in skin necrosis in SSc are presented.

Scientific validation of three-dimensional stereophotogrammetry compared to the IGAIS clinical scale for assessing wrinkles and scars after laser treatment.

Measuring outcomes from treatments to the skin is either reliant upon patient's subjective feedback or scale-based peer assessments. Three-Dimensional stereophotogrammetry intend to accurately quantify skin microtopography before and after treatments. The objective of this study is comparing the accuracy of stereophotogrammetry with a scale-based peer evaluation in assessing topographical changes to skin surface following laser treatment. A 3D stereophotogrammetry system photographed skin surface of 48 patients with facial wrinkles or scars before and three months after laser resurfacing, followed immediately by topical application of vitamin C. The software measured changes in skin roughness, wrinkle depth and scar volume. Images were presented to three observers, each independently scoring cutaneous improvement according to Investigator Global Aesthetic Improvement Scale (IGAIS). As for the results, a trend reflecting skin/scar improvement was reported by 3D SPM measurements and raters. The percentage of topographical change given by the raters matched 3D SPM findings. Agreement was highest when observers analysed 3D images. However, observers overestimated skin improvement in a nontreatment control whilst 3D SPM was precise in detecting absence of intervention. This study confirmed a direct correlation between the IGAIS clinical scale and 3D SPM and confirmed the efficacy and accuracy of the latter when assessing cutaneous microtopography alterations as a response to laser treatment.

Complications of Cosmetic Artificial Iris Implantation and Post Explantation Outcomes.

PURPOSE: To report complications of cosmetic artificial iris implantation and explantation outcomes. DESIGN: Retrospective case series. METHODS: Medical records of 12 patients (24 eyes) who presented to us after being implanted with cosmetic artificial irises elsewhere were reviewed. Data collected included baseline demographics, presenting symptoms, examination findings, and management outcomes. RESULTS: Eight eyes had NewColorIris implants and 16 had BrightOcular implants. The mean interval from cosmetic iris implantation to presentation was 61.7 ± 60.0 months. The mean follow-up after explantation was 35.5 ± 38.1 months. Complications at presentation included iris abnormalities (11 eyes, 45.8%), elevated intraocular pressure (8 eyes, 33.3%), corneal edema (6 eyes, 25%), intraocular inflammation (5 eyes, 20.8%), and cataract (4 eyes, 16.7%). Surgical interventions included cosmetic iris removal (19 eyes, 79.2%), cataract extraction (7 eyes, 29.2%), corneal transplantation (7 eyes, 29.2%), and glaucoma surgery (4 eyes, 16.7%). Complications at the last follow-up examination included native iris defects (11 eyes, 45.8%), persistent glaucoma (7 eyes, 29.2%), cataract (5 eyes, 20.8%), corneal edema (4 eyes, 16.7%), and intraocular inflammation (2 eyes, 8.3%). The mean logarithm of the minimum angle of resolution was 0.56 ± 0.47 at presentation and 0.78 ± 0.88 at the last examination (P = .30). The mean intraocular pressure was 22.7 ± 15.8 mm Hg at presentation and 13.4 ± 6.99 mm Hg at the last examination (P = .02). CONCLUSION: Cosmetic iris implantation was associated with serious complications at the time of presentation, and adverse sequelae persisted for years after explantation.

Complications of Cosmetic Surgery Tourism: Case Series and Cost Analysis.

BACKGROUND: Cosmetic surgery tourism is increasing exponentially. Patients seek cosmetic procedures within the United States and abroad, lured by lower cost procedures, shorter waiting lists, and affordable airfare and hotel accommodations. Unfortunately, operations are often performed by non-board-certified plastic surgeons, sometimes not even by plastic surgeons. Preoperative counseling, frequently limited to a video-chat with an office secretary, provides inadequate discussion regarding potential complications. Postoperative care is careless and rarely involves the operating surgeon. Complications are frequent, with management falling into the hands of plastic surgeons unfamiliar with the patient's care. Furthermore, the physician, rather than the patient or hospital, faces the largest cost burden. OBJECTIVES: The authors sought to explore their institution's experience treating complications of cosmetic tourism and investigate associated costs. METHODS: The retrospective review of 16 patients treated for complications related to cosmetic surgery tourism plus cost analysis revealed a substantial discrepancy between money saved by undergoing surgery abroad and massive costs accrued to treat surgical complications. RESULTS: The most common complication was infection, often requiring surgery or IV antibiotics on discharge. Mean cost per patient was $26,657.19, ranging from $392 (single outpatient visit) to $154,700.79 (prolonged admission and surgery). Overall, the hospital retained 63% of billed charges, while physicians retained only 9%. The greatest amount paid by any single patient was $2635.00 by a patient with private insurance. CONCLUSIONS: Cosmetic tourism has severe medical repercussions for patients and complications that burden hospitals, physicians, and the US medical system. Physicians treating the complications suffer the greatest financial loss.