Cosmetic Tourism: An Infectious Disease Burden

Goals/Purpose: In this age of globalization, patients may seek to have their aesthetic surgeries performed in foreign countries anticipating significant cost-savings compared to perceived prohibitive out-of-pocket costs in the US. Given the transient nature of their stay in the country of surgery, post-operative follow-up is often sub-optimal. These patients frequently seek care in the US for complications, the burden falling on the US healthcare system. Non-standardization of aseptic surgical facilities and technique leads to an increased risk of infectious complications.  Management of these complications represents a resource burden to the healthcare system and poses a clinical danger to the general population. Travel and surgery in uncontrolled settings, with their disparate macro-biomes, facilitates translocation of potentially dangerous infectious microbiota. This study investigated the microbiological data from a series of patients who sustained infectious complications from their cosmetic tourism.

Methods/Technique: A retrospective chart review was conducted on patients who underwent aesthetic surgery outside the US and were evaluated by the plastic surgery service from 1/1/2005 - 4/3/2016. Data included the patient demographics, type of surgery performed, country of surgery, complications, management of complications, cost of care, and microbiology data.

Results/Complications: Forty-one patients were evaluated for complications following their cosmetic tourism procedure. The most frequently documented countries of surgery were the Dominican Republic (25) and Colombia (7). The most common surgeries were abdominoplasty(11), abdominoplasty with liposuction(8), breast augmentation(5), and breast augmentation with mastopexy(4) . Three patients received silicone injection into various sites including the lips, chin, breasts, hips, and buttocks. Nineteen patients suffered infectious complications which included cellulitis (4), cellulitis with abscess (12), and necrotizing soft tissue infections (2). Two patients with necrotizing infections required emergent debridement and protracted stays in the ICU. Two patients had undergone abdominoplasty with subsequent abscesses requiring serial operative debridements. The most commonly encountered infectious agents were atypical Mycobacterium species, including Mycobacterium abscessus and Mycobacterium chelonae, and Pseudomonas aeruginosa. Other atypical bacteria encountered included Peptostreptococcus magnus, Alcaligenes xylosoxidans, Enterococcus faecalis, Coryne bacterium, Acinetobacter baumannii, Bacillus sp, Prevotella bivia, and Candida parapsilosis.

Conclusion: The growing pervasiveness of cosmetic tourism poses a significant resource burden to the US healthcare system and an atypical infectious risk. Atypical Mycobacterium infections were most common, followed by Pseudomonas aeruginosa. Introduction of novel flora may evolve into an epidemiological dilemma.  More research is needed pertaining to the infection risks of foreign surgery to optimize antibiotic stewardship. Cosmetic tourism is a natural consequence of the commodification of aesthetic surgery, reducing the plastic surgeon and his craft to fungible goods. Education of the general public will help dispel the misplaced notion of equivalency between board-certified US plastic surgeons and providers of variable training in foreign countries by highlighting not only the qualitative aspects of aesthetic surgery, but also the safety concerns regarding the risk for postoperative complications, including infections that may lead to permanent disfigurement and possibly death.

References:
Melendez MM, Alizadeh K. Complications from international surgery tourism. Aesthet Surg J. 2011;31:694–697.

Franzblau LE, Chung KC. Impact of medical tourism on cosmetic surgery in the United States. Plast Reconstr Surg Glob Open 2013;1:e63.