Perception of Risk Among Aesthetic Plastic Surgeons

Goals/Purpose:

Within aesthetic surgery, there exists a spectrum of safety profiles of various procedures. With continuous innovation in Plastic Surgery, new procedures are constantly introduced. A number of these procedures are generally safe, but have potential for very rare yet serious complications. Many surgeons stray away from these procedures due to safety concerns while continuing to regularly perform more common, well-established operations that arguably pose greater risk for serious complications. The purpose of this study is to survey the Aesthetic Society membership to elicit perception of risk of several novel or less mainstream procedures, and to compare against perceived risks of more common procedures.

Methods/Technique:

With the approval of the Aesthetic Society Executive Committee, a 24 item survey was sent out to all members of the Aesthetic Society. The data was analyzed using univariate and descriptive statistics. This study was deemed exempt status by the University of Michigan Institutional Review Board.

Results/Complications:

A total of 198 surveys were returned, 163 of which were completed. 91% of respondents were board certified by the American Board of Plastic Surgery. 78% of respondents were male, and the average age reported was 59 (range: 36-77). 93% of respondents have been in practice for over ten years. When asked to select the top three procedures performed in their practices, the most common responses were breast augmentation (n=101), abdominoplasty (n=87), and facelift (n=51).

With regard to novel and less mainstream procedures, 51% of surgeons said they do not perform filler rhinoplasty in their practice, with danger to patient being cited as the most common reason for avoiding the procedure. 46% of surgeons reported that they perceived the overall complication rate of filler rhinoplasty to be 5% or higher, with 24% believing skin necrosis to be the most common complication. 33% believe the risk of blindness with this procedure to be 0.1% or higher.

51% of respondents perform gluteal augmentation with fat grafting (“Brazilian Butt Lift”) in their practice. Of those who do not, 61% cited danger to patient as their reason. 70% of surgeons believe the complication rate of BBL to be 5% or higher. 46% of respondents believe the risk of fat embolism to be 1% or higher.

91% of surgeons do not perform submandibular gland excision with facelift, with nearly half of them reporting danger to the patient as their concern. 73% of surgeons believe the risk of expanding hematoma with airway compromise to be greater than or equal to 0.1% in this surgery.

Overall, 44%, 61%, and 80% of surgeons believe the risks of filler rhinoplasty, BBL, and resection of submandibular glands, respectively, to be “borderline”, “mostly unacceptable”, or “unacceptable”. This was compared to abdominoplasty where 96% reported the risks to be “minimal” or “acceptable.”

Of note, for all three procedures (filler rhinoplasty, BBL, and resection of submandibular glands), surgeons overwhelmingly reported learning how to perform them at a conference, from a colleague, or from self-study, with virtually none reporting learning in residency or fellowship.

Conclusion:

Overall, Plastic Surgeons perceive risks of certain procedures to be higher and more severe than available data suggests. The true complication rate of filler rhinoplasty hovers at around 1.6%, with no skin necrosis or blindness recorded in any large cohort studies, far below the perceived rates of these complications.¹ A recent meta-analysis reports that gluteal augmentation with fat grafting has a 7% complication rate, which is consistent with the study population’s perceptions. The risk of fat embolism, however, is approximately 0.1%, a number significantly overestimated by 46% of respondents.² There has only been one paper describing a single episode of expanding hematoma causing airway compromise in the setting of submandibular gland excision, giving it a 0.8% incidence in that particular study.³ Given the lack of other data on the topic, it is likely that it is even less common. All in all, Plastic Surgeons over-estimate the risks of these procedures, particularly filler rhinoplasty, which the data suggests is quite safe. Interestingly, large numbers of respondents rated these three procedures as having significantly more unacceptable risk profiles when compared to procedures such as abdominoplasty, which has a 0.3-1.1% risk of thromboembolism (a potentially devastating complication), or augmentation-mastopexy, which has a 23% complication rate. It appears that Plastic Surgeons overestimate the risk of procedures with which they are less familiar in comparison to more commonly performed operations.

Citations:

1. Williams LC, et al. Nonsurgical Rhinoplasty: A Systematic Review of Technique, Outcomes, and Complications. Plast Reconstr Surg. 2020 Jul;146(1):41-51.
2. Condé-Green A. et al. Fat Grafting for Gluteal Augmentation: A Systematic Review of the Literature and Meta-Analysis. Plast Reconstr Surg. 2016 Sep;138(3):437e-46e.
3. Mendelson BC, Tutino R. Submandibular Gland Reduction in Aesthetic Surgery of the Neck: Review of 112 Consecutive Cases. Plast Reconstr Surg. 2015 Sep;136(3):463-471