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    Exploring Cosmetic Surgery Tourism with Dallas Surgeon Dr. Sam Jejurikar

    In this podcast between three plastic surgeons (, , Dr. Sam Jejurikar) they discuss the dangers of medical tourism, specifically the risks associated with getting cheap cosmetic surgery in other countries. As medical professionals who have witnessed the devastating aftermath of bad surgeries, they speak passionately about the importance of patients doing their research, ensuring they are going to reputable surgeons, and staying for an appropriate amount of time to monitor their recovery. They also touch on the issue of insurance coverage for complications from cosmetic procedures obtained overseas and the ethical implications of providing care to patients who may have made a risky decision to save money.

     Dr. Sal Pacella: Well, good morning, everybody. We’re here for another podcast. I’m Doctor Sal Pacella from San Diego, California. My Instagram handle is at San Diego Plastic Surgeon. We have Sam Rhee, Doctor Sam Rhee from Bergen, New Jersey, at Bergen Cosmetic, and of course, Doctor Sam Jejurikar at Dallas Plastic Surgery out of Dallas, Texas. How are you today, gents?

    Dr. Sam Jejurikar: Doing awesome. How are you?

    Dr. Sal Pacella: Fantastic. So, we are going to talk about a very interesting topic today medical tourism, specifically the pro and pitfalls, and advantages of going out of the country out of the US for cosmetic surgery. Prior to doing so, let’s go through our regular disclaimer.

    Dr. Sam Jejurikar: Yeah, and just one thing before the disclaimer, Doctor Rhee, I always get it confused. He’s from Paramus, New Jersey, Bergen County, right?

    Dr. Sal Pacella: Oh, Bergen County. Minus takes.

    Dr. Sam Jejurikar: No, I screwed it up on the last shows. I feel like I need to make a mess. So, this show is not a substitute for professional medical advice, diagnosis, or treatment. This show is for informational purposes only. Treatment results may vary based on the circumstances, situation, and medical judgment after appropriate discussion. Always seek the advice of your surgeon or other qualified health provider with any questions you may have regarding medical care. Never disregard professional medical advice or delay seeking advice because of something you may have seen on this show. Back to you, Doctor Pacella.

    Dr. Sal Pacella: Alright, gents. Well, so this is a very interesting topic. I think that had some notoriety in the news cycle the last few weeks about going out of the country for plastic surgery care. And this seems to be quite popular in some of our southern states. Obviously, in San Diego, I have seen a lot of patients go to Tijuana or south of the border for cosmetic surgery procedures, and of course, many kinds come back over the border with complications. Sam, I know in Dallas you probably see a bit, and Sam, in New Jersey, I’m sure you probably see people flying back and forth from the Caribbean. So, I’m just curious about your experience with this and what you see as some potential issues.

    Dr. Sam Jejurikar: I guess I can start. So yeah, I definitely have seen many patients who are kind of breaking the few types of medical tourism, international and domestic. From an international standpoint, we see lots of patients flying from the Dominican Republic to Mexico to Turkey. Um, that’s a very popular destination these days that we’re seeing. And obviously, there’s selection bias in terms of the patients that we are seeing. Someone is having a good result or not having any problems. We’re probably not hearing anything about it. Unfortunately, with some frequency, whether it’s an ERs in the community around us or calls to our office just seeking post-operative care, there are a lot of patients that seem to have these procedures that are being done and then have post-operative complications and no one actually takes care of them. It puts, but that’s all sort of in a difficult situation. Because our goal is to try to help people, but our goal obviously has to be to sort of take care of the patients that we’ve taken care of first, and sometimes we’re stretched within to give people the care that they need. Sam.

    Dr. Sam Jejurikar: Absolutely. I see a fair number of patients or not. We are contacted at our office by a fair number of patients. Let me rephrase that, especially from the Dominican Republic. And I think the biggest issue, as Sam has mentioned, is follow-up care and complications. I like at least two or three times a week, we’ll get a call from someone who says, I had a tummy tuck done out of the country, and I have a lot of redness now, and I’m really worried about it. Or I had a breast augmentation done, and one side is really getting bigger and bigger, and I called my doctor in the other country, and they said just go see a doctor, and they’ll drain it for you. You, no problem. It’ll be totally fine. These are the type of things we get constantly from our office, and it’s really a dilemma for patients. I mean, patients never expect to have complications. But when they happen, they can be devastating when you have no support, no help, and no one near you to help deal with them.

    The Ethics of Plastic Surgeons in Dealing with Overseas Surgery Complications

    Dr. Sal Pacella: I agree. So again, you make a great point, Sam which is the selection bias, right? And let me also say this. I am a member of the aesthetic society, and I’m also a member of the ISAPS, which is the International Society for Aesthetic Plastic Surgery. I have certainly not seen that the best plastic surgeons are in the United States. That’s clearly not the case. One of the best eyelid surgeons in the world is an Aman Jordan Mo Al-Ghoul, who’s a good friend of mine. We just did a couple of podcasts on body contouring surgeons Doctor Foyas in Columbia. So, but there are bad surgeons in the United States, and they’re bad surgeons internationally, and what’s not necessarily what’s important is the complication issue, not necessarily where you’re going, right? And I would say that at least a couple of times a month, my office gets calls about chronic seroma or an infection.

    I would say that the worst things I see are twofold drained. So, people come back just a short time after plastic surgery so weak and have a large pocket of puffs or infection, and then they find themselves in the ER one night, okay? And that causes some issues because many insurance companies don’t pay for complications related to cosmetic surgery, so they may be stuck with a big ER bill or a secondary revision surgery bill. The second thing I’ve seen, which sometimes comes months after the case, is there has been a warning from our professional societies about mycoplasma bacteria in the setting of liposuction, and this is due to really us Substandard sterilization of the liposuction cannulas. So, if you think about it, we’re taking these big metal cannulas. They’re hollowed out and were passing them back and forth into the subcutaneous tissue of the abdomen. And if you have bacteria or some sort of really resistant bacteria in that cannula, it is conceived throughout the entire abdomen. And many years ago, about 10-12 years ago, horrific story. A young lady, 24 years old, came to see me, and she had liposuction of her abdomen, and she had at least I counted at least 35 pockets of small areas of puffs all the way throughout her abdomen. I literally had to make 35 small cuts to excise each of these puck pockets. It’s pretty tragic.

    Dr. Sal Pacella: So, what I would say is just kind of the follow up in what you suggest, there are definitely great plastic surgeons internationally. Definitely, there’s a very good one, but the thing is, if you look at the motivation for why people are typically going overseas. The ones that are going for medical tourism are not doing it because they’re necessarily seeking out the best plastic surgeons that they can. Many times, they are doing it because they’re trying to seek out the cheapest plastic surgeons that they can, and they are drawn into the fact that they can get a package price that oftentimes includes their airfare, their accommodations per week to 10 days, and their surgery. And I’ve had many complications. I imagine you guys have had many complications. We have the ability to take care of our own complications here. And we’re all board-certified plastic surgeons. We’re members of the aesthetic society. We’re members of the American Society of Plastic Surgeons. When people are going overseas, they’re not often times knowing what the credentials are of the surgeon that’s doing their procedures.

    There’re many stories in some of these places, like the Dominican Republic in Mexico, where people are going, where there are clinics that are doing high volume. There may be some well-trained plastic surgeons, but there are many other people working underneath them that may not have the same level of credentialing, and then we don’t know about the credentialing of the facilities. I do all of my procedures, and I know you guys do as well in fully accredited surgery centers that get inspected on a regular basis by organizations in the US, whether it’s hospital accreditation or surgery center accreditation, to make sure that they’re up to standards for sterilization for safe practices. You travel overseas, and your primary motivation is price. There’s no way to be sure of these whether or not the same level of gone into making sure your procedure will be as safe as possible.

    Dr. Sam Rhee: It’s true.

    Dr. Sal Pacella: Quality, quality comes with a premium, and I think patients need to understand that. Go ahead, Sam. Sorry.

    Dr. Sam Rhee: I think so. The other thing I have seen is that patients will often not necessarily be the best candidates for a procedure or multiple procedures. I’ve seen patients who were extremely high BMI and wanted multiple procedures. Maybe they wanted a tummy tuck, liposuction, breast augmentation, or arm lift all the same time, and they had seen either the cost was too prohibitive to do it locally or there wasn’t anyone who felt like they were good candidates to have this done in the United States. So, they ended up traveling somewhere where someone said; I will do all of these procedures for a very low price. And it’s very tempting for patients because they feel like they don’t have the means or possibility to achieve what they really want. But what happens with a lot of these patients is that they run into complications. Because when you do these high-risk procedures on patients, even in the safest of settings, you can run into real problems. And second of all, these surgeons will often do really poor jobs doing all of these procedures.

    I’ve seen this time and time. Again, there are some places where I’ve seen patients say they routinely blood transfuse everyone, and I was like, what, like for cosmetic surgery. They’re like, yes. You have to purchase in advance your blood transfusions in order to make sure that you get them during the procedure. Because if not, there will be patients that die if you don’t buy it in advance. So, there’s this whole subculture of these patients who are so desperate that they’re willing to literally risk their lives, and they know this because they feel like this is the only way that they achieve their result. And I don’t want to judge patients for wanting what they want, but in this case, it’s literally not worth it for you, your family the people around you to try to risk your life for something that it it’s not worth it.

    The Importance of After-Care and Risks of Medical Tourism

    Dr. Sal Pacella: So, let me just get this straight. So, you’re saying that if you don’t purchase your blood transfusion ahead of time, they won’t give it to you.

    Dr. Sam Rhee: That’s correct. And they say, for all the other expenses you might need, more bandages, more medications, bring cash. Because they’re not going to take your credit card down there, so make sure and at a lot of these places are like, if you don’t have someone who speaks Spanish well, they’re not going to treat you well. So, there’s this whole subculture of patients where they’re like giving each other’s tips. This plastic surgeon or this cosmetic surgeon recently had a couple of deaths. So, avoid that one; go to this one. Like, it’s when you look at the discussion that many of these patients have on Facebook groups or other locations, it’s truly scary what they’re willing to put up with to risk in terms of trying to achieve a result. Honestly, having seen this and seeing it first hand in terms of these patients, it’s not worth it. And so yeah, go ahead.

    Dr. Sal Pacella: So, let me ask you a question, and you alluded to this earlier. Which was the patient coming to your office, or you see him in the ER, and they say I called my original surgeon, and they said just go to the ER, somebody will take care of it for you; you’re going to be fine, okay? Let’s reverse the roles here. Let’s say somebody came to see you in Jersey or you in Dallas from outside the country or, let’s say, from another part of the United States. How would you broach that subject if you had a complication?

    Dr. Sam Jejurikar: I can go first because I do have this scenario happen a lot in my practice, and then I’ll treat people from other States every week. I think we have to break it into different phases of their care. I will try to make sure that they stay in a conceptible amount of time in Dow Fort Worth afterward. So, what they’re doing, is a tummy tuck with liposuction on someone. I’ll tell them I want them to stay in town for approximately two to three weeks postoperatively. I want to make sure they get to that initial perioperative phase where there are no substantial issues. I put them on the visit schedule postoperatively via telemedicine postoperatively, so I’m still following up with them at the same intervals I would be if they were local. They have a direct line to me. They have my office number and my cellphone number, so they can get a hold of me if they need me with anything. But then I have an extensive network of friends who are plastic surgeons, board-certified plastic surgeons in pretty much any portion of the country.

    My patient lived in New Jersey; I’d say, Sam, I need your help with something; I know UBD said the same thing to me. They’re in San Diego. I would do the same thing with Sal, and I know you would do the same for me. That’s the thing like we have a network of people in this country who we can guide them to should something happen. Usually, I think you guys would agree most complications of a significant nature are detectable within the first, you know, a few days to a couple of weeks after surgery. So, you can get them past a certain point. Typically, you don’t see a lot of things happening, but you can still care for them very well or somewhere else. But you have to keep them around for a long enough period of time.

    Dr. Sam Rhee: Absolutely. I think the biggest thing that we all do as plastic surgeons is make sure our after-care is appropriate regardless of if they’re near or far. And trust me; it’s sometimes it’s a struggle for someone. I’ve had patients all over the Northeast, even Long Island, trying to get across that Cross Bronx expressway backed over to see me. I’m telling these patients, please take that hour drive, hour and a half drive over, and they’re like, I’m fine, just like let me just talk to you on the phone or let me just zoom you, and I’m like okay, fine. But if there’s anything you got, I want to see it in person. So, I think we’re all pretty fanatic about making sure that the biggest thing that we can do to not treat complications is to avoid them. And a lot of times, the post-op care that we’re providing is literally preventing complications.

    The fact that we are keeping up on things that we’re maintaining communication with our patients. I would find it abhorrent if I just sent a patient off after surgery and said good luck. If they called me for something, say, okay, find someone else. Like I find that just completely antithetical to what we do as plastic surgeons. Our job is to shepherd them through the whole course, not to just operate and leave them alone.

    Dr. Sam Jejurikar: Well, it’s a completely different business model if you think about it, Sam, right? If you’re doing low-cost surgery, you have to do high-volume surgery to make that work, and if you really want to make it work, you need to do really high-volume surgery, which means it becomes less about the individual doctor-patient relationship, and it’s more about shoveling people through a business. So, a lot of these patients don’t even see the doctor until right before surgery, and your screening is done by maybe a nurse, maybe not even a nurse, maybe a receptionist. So, it’s a totally different model of doing business, and it’s not geared toward that doctor-patient relationship at its very core.

    Dr. Sal Pacella: I find myself in this scenario not infrequently, either. I see a lot of complex revisional eyelid surgery from all over the country. And unfortunately, in the eyelid, although you do get complications early on, a lot of these things sort of fester for a long period of time, three months, six months a year. Unfortunately, we’re not in this scenario where I can just send them away after two weeks. So, I have a specific strategy that I tell patients. I say, if you’re coming to see me fix this problem, I want it to be successful for you, but so it’s a two-way street. I’m certainly willing to send you home at an appropriate time, but you have to be willing to come back to see me at a moment’s notice should there be any problems because it’s critical for me to see you as soon as possible if you develop chemosis of the eyelid or lid down position that because there are strategies that I have to employ very relatively expeditiously in order to stop that problem from getting worse. So, it’s a big challenge. Big challenge.

    Dr. Sam Rhee: I think, go ahead.

    Dr. Sal Pacella: Yeah, go ahead. Sorry.

    Dr. Sam Rhee: No, go ahead.

    Dr. Sal Pacella: So, let me ask this question here. Let’s shift gears for a second. So how do you feel should your domestic health insurance pay for complications when you go out of the country for cosmetic surgery? So, when you show up in the ER with a rip-roaring septic infection, what do you think should happen?

    Dr. Sam Rhee: I was just about to; I knew you were going to talk about this, which is why I said go ahead. Right now, most commercial insurances do not cover complications from cosmetic procedures, and that is really one of the problems that patients have coming back, and that’s also one of the reasons why I’m very reluctant to see anyone who’s had a complication from outside the country. It’s not that I don’t feel for these patients, that I sympathize with them, that I understand that they’re going through a really difficult time. It’s that they just spent money, even if it was less money than they would have in the United States. They just spent a big chunk of their money traveling, flying, getting care, coming getting surgery, coming back, and then, they have this complication that they show up in an ER for where they now have to pay out of pocket for additional care. And this was something I talked about with one of the other plastic surgeons who’s part of the ASPS ethics committee, Doctor Bajaj.

    Now you’re charging these patients for care when they’ve already shelled out a ton of money, and these patients are already in a financial situation. As a surgeon, if you end up seeing someone in the ER, you are obligated to take care of them in the immediate emergent period. But then your legal obligation to take care of them after you’ve gotten them through that immediate emergent situation is no longer there. But they often have a lot of residual cosmetic issues. Scarring, huge ugly cosmetic issues that they need or want to get fixed, and at this point, I didn’t know who the surgeon was. I don’t know exactly what happened to them. This is a tremendous time and money investment both for the patient and for me. That’s not something I take lightly, and so honestly; I don’t know if insurance will ever pick up the bill for these things. I don’t think they ever will, so I think it’s a good point.

    Insurance isn’t increasing benefits, so just reducing them, and I don’t, and honestly, as a provider, although I feel for these patients, I try to stay away from them as far as I can.

    Dr. Sam Jejurikar: Yeah, I mean, just to kind of second what Sam is saying, I mean, they don’t cover complications related to elective cosmetic surgery in the US. So, they’re not going to magically cover it for people that are having surgery internationally. I mean, in the US, there are supplemental insurance policies that all of my patients are required to buy to cover cosmetic complications that would potentially happen after surgery. Because we explain to them that your normal health insurance is not going to cover these complications, it’s only eligible to board the patients of board-certified plastic surgeons, and I don’t know if you guys use it or not. I think your question, though, was should they cover it, right? Not does it cover it? Was this more of a trying to get us should our feelings should?

    Yeah, I think it should. I think it should also cover complications related to elective cosmetic triggers. Because if I go skiing and I break my arm, that was an elective choice as well. I broke my arm, and I engaged in a high-risk activity, but the insurance company doesn’t give me a hard time about fixing that. So, yeah, I believe they should. I also know that they don’t. So, I don’t know what my opinion is; my opinion doesn’t count for anything. Hitting it. That’s a personal belief. I mean, it’s only the choices. Any sort of thing that’s a traumatic injury. There’s usually some sort of choice that was involved that led to that. Get the insurance companies don’t draw this name distinction.

    Dr. Sal Pacella: I think we clearly see the whole gamut. I’ve seen patients come in lordly septic from crossing over the border, then have to go for emergent surgery, ICU admission, presser support, everything. From minor complications, scar deformities, etcetera, a month later, it’s a tough pill for me to swallow to think that you know any insurance company wouldn’t pay for someone on the verge of death regardless of the choice they make. I mean, I personally feel that if it’s a life-threatening complication or a complication that’s related to significant additional morbidity like inspection or requiring an urgent surgery within, you know, 90 days of the global period. Probably something insurance in a society we should really consider covering. But some of the other complications related to how things look or scarring, etcetera, I’m a little bit born about. I mean, patients have made this decision, and I think they’re smart enough to know that there are risks.

    Dr. Sam Jejurikar: So, I think you can break it down into life-threatening complications, medical complications, and then cosmetic complications.

    Dr. Sal Pacella: Right.

    Navigating Complications from Overseas Cosmetic Surgery: Medical vs. Cosmetic Issues

    Dr. Sam Jejurikar: And I would certainly draw a distinction between cosmetic outcomes because there’s no medical necessity to get those fixed. One of the worst complications I saw was necrotizing fasciitis after a Brazilian butt lift. By the time I got consulted, general surgeons had already.

    Dr. Sal Pacella: Sam, real quick. Tell us what necrotizing fasciitis is.

    Dr. Sam Jejurikar: Necrotizing fasciitis, they rapidly face sending infection, a particular type of bacteria that rapidly spreads. And if you don’t, treat it by urgently de-breeding all of the skin and all the fascia, which is the way it runs on top of the muscles.

    Dr. Sal Pacella: Flesh-eating bacteria, right?

    Dr. Sam Jejurikar: Right. Thank you. Yeah. So, if you don’t do rapid surgical de-breeding, patients will die. So, by the time I got consulted on this patient, she’d already had the life-saving aspect of her procedure done. General surgeons had removed all of her buttocks on both sides and had skin grafted on her as well. So, not just have a horrific cosmetic problem. So, at that point, then, it is technically cosmetic surgery to fix it, and you have to point to the patient that it’s going to take multiple, multiple, multiple operations to get her to look somewhat possible. It’ll never be good, and it’s probably all coming out of pocket, and that’s the hard conversation to have with somebody.

    Dr. Sam Rhee: I mean, I realized that we are biased; we are making our money doing cosmetic surgery, and the people that go out of the country, we’re losing income potentially to other plastic or other cosmetic surgeons in these other countries. So, it’s easy for other people to look at us and say, well, of course, they’re going to say don’t go overseas. Don’t go to another country. Don’t go for the cheap option. And you’re right. Like I understand that we may not be coming from a place where people would find us authentic. But I can only tell you that there’s not one of us who would ever send a mother, a sister, or a friend to go overseas, no matter what, and that’s how I treat my patients.

    Dr. Sam Jejurikar: So, I disagree. I actually disagree with that statement.

    Dr. Sam Rhee: Oh really?

    Dr. Sam Jejurikar: And yeah, well, I’ll tell you why because I think we got to get back to that first point that Sal just said. So, I’ve talked to my wife about additional body contouring surgery. It’s a theoretical conversation that we have. And I would, she’s like, who should I go to? And I said you need to go to Colombia to Alfredo Hoyas. And she’s like, you want to send me to Columbia? I’m like one of the best people of not the best people in the world to do this procedure.

    Dr. Sam Rhee: Okay.

    Dr. Sam Jejurikar: He is a world plaster, and then she needs to do exactly what Sal, me, you do with any of our patients that come from somewhere else. You need to stay there for in appropriate amount of time. You need to be willing to go back should any complications arise. She’s done her research as to who this particular surgeon is. The bottom line is you’re going to go overseas. It got to be the same criteria that we use with our own patients. Do your research. Make sure you’re going to a person that is reputable and knows what they’re doing. Stick there for in appropriate amount of time. Go back to them with complications that happen, and the problem is what we’re seeing and what we’re talking about isn’t that. What we’re seeing is people that are just going to some sort of factory coming back here and having no follow-up of any kind.

    Dr. Sam Rhee: You’re 1000% correct.

    Dr. Sal Pacella: I think when you’re questioned, Sam, I think your question, if I could take the opportunity to rephrase that, would you ever send your family member yourself to go overseas for pure costs for purely saving money.

    Dr. Sam Rhee: That’s correct. You’re right, and I would never 

    Dr. Sal Pacella: Doctor Hoyas is not going to be inexpensive.

    Dr. Sam Jejurikar: Hell no.

    Dr. Sam Rhee: No, if anything, it may cost more than all of us, but you’re right, you’re 1,000% right. Never, I would never have any of my family members do anything for the cost of it, and Sam is 100% correct. I would do the research. I would make sure that I did the due diligence to go overseas and have the surgery in what I would think would be the right way. So, both of you guys corrected me, and I agree 1000% with that. I appreciate that. Yes, you’re right.

    Dr. Sal Pacella: Any Strategies for dealing with the cartels when you’re overseas?Anyone. That’s too soon. Sorry.

    Dr. Sam Rhee: I have one of my; I mean, one of the guys I trained with is from Kali, and he’s an amazing surgeon. So, I would have to ask him how to deal with it.

    Dr. Sal Pacella: I mean, I have not done this lately, but that recent episode was just absolutely tragic.

    Dr. Sam Rhee: It’s tragic.

    Dr. Sal Pacella: I mean, it saddens me dearly. So, well, that note, gents, thank you for your input. I really appreciate the commentary, and I guess that’s it.

    Dr. Sam Jejurikar: Have a good day, gentlemen.

    Dr. Sam Rhee: Alright.

    Dr. Sam Jejurikar: Take care.

    Dr. Sam Rhee: Thank you so much.



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