In the 1970s an uncomplicated facelift required a 4.5-day hospital stay. There have been huge paradigm shifts in hospital stays for all surgical procedures and currently, most cosmetic surgery is not performed in the hospital environment. There are numerous reasons for this including exorbitant hospital costs, presence of nosocomial infections, lack of insurance coverage for cosmetic surgery, having cases bumped by emergencies or other surgeons running behind, and lack of privacy for elective cosmetic procedures.
Having a fully accredited surgery center in one’s office offsets the need to operate in a hospital and all the negatives associated with it. It gives the surgeon total control of his or her operating environment. There are no other surgeons to run late or bump your case. Surgery is much more cost effective compared with hospitals. Safety is usually enhanced because of the fact that the same people do the same job all day every day which eliminates shift changes and related problems. There is no worry about infections from other patients. Because cosmetic procedures are usually very personal and discrete, patients can come and go without exposure to scores of employees who work in a hospital environment. Also small offices usually have one or two anesthesia providers who work on a continual basis and this prevents surprises that can occur with random anesthesia providers. Finally, convenience for the doctor, staff and patient is unparalleled. I used to spend a lot of time driving back and forth from the hospital, and now my operating room is just several steps away.
Office accreditation is not a panacea and has relative drawbacks. First and foremost, the surgeon is the captain of the ship and every good and bad thing falls on his or her shoulders. If an emergency occurs in the hospital environment, there are dozens of trained personnel immediately available. In your office, it is you and your staff. For this reason, the surgeon must use discretion as to which cases are not suitable for the office surgery center. I never take a chance and I cancel cases 5 to 6 times per year because the patient has some medical condition that may put them at risk. As I have stated many times, a big part of having a good reputation and being safe has to do with picking the right patients. Never take a chance with a patient’s health.
One of the best things I have ever done in my professional career was having my office and surgery center accredited. I have hundreds of colleagues who will echo the same remarks. Many surgeons are hesitant to pursue this because of the perceived extra work and expense. Also many surgeons mistakenly believe they have to physically rebuild their facility. In reality, bona fide accreditation is attainable for the average practitioner and facility if the surgeon and staff are willing to rise to the requirements. The biggest misconception is that accreditation is a bricks and mortar undertaking when in reality it is actually more about policies and governance ( Fig. 4.1 ).
The basis of accreditation is to ensure a safe, efficient, and accountable facility to better serve patients, surgeons, and staff by meeting or exceeding nationally recognized standards. In effect, you are making your office function as a small hospital. This definitely ups the ante for work and paperwork and is not something to be taken lightly. In short, it is a lot of work, mostly paperwork, but it unequivocally will make you a better and safer surgeon with a better and safer staff, facility, and patient experience.
The most common organizations for outpatient, office ambulatory surgery center accreditation are: Accreditation Association for Ambulatory Health Care ( www.AAAHC.org ), Joint Commission on Accreditation of Healthcare Organizations ( www.jointcommission.org ), and the American Association for Accreditation of Ambulatory Surgery Facilities ( www.AAAASF.org ).
Some examples of changes to routine office protocols include the requirement to dictate all surgical operation reports, quality review studies for sterilization, malignant hyperthermia rehearsal, infection prevention and reporting, studies for patient waiting times, peer chart review, impaired physician and operating room fire rehearsals, and credentialing all users of the facilities operating facility. Again, this is all very paperwork intense. Trying to become accredited on your own can be a task of awesome proportions. I highly recommend that any practice that is interested in becoming accredited seek the services of professional accreditation consultants. It is not very expensive and they coach the office and staff through every step of the way, including mock accreditation site visit. Although I know doctors who have become accredited without a consultant, I can speak from experience that the consultant route is much easier on the doctor and staff. Finally, one misconception regarding accreditation is the fallacy that the surgeon must do all the work. In actuality, the staff does 90% of the work and record keeping, and the surgeon is the team leader. Having one nurse or exceptional employee to handle all the accreditation work makes this task very straight forward. Because accreditation comes in 3-year cycles with office inspections, having a stable employee who will be there for a long time is preferable.
Many young surgeons will not have the luxury of having an accredited surgery center in their office. Some new surgeons will have hospital privileges and perform cosmetic procedures there. That is a good option, but takes the surgeon out of their office, adds significant expense for the patient, increases exposure to infections, and lacks the privacy of an office surgical center. If a surgeon does not have hospital privileges, they may be performing surgery in a minor surgical suite in their office. Usually, novice surgeons perform smaller procedures, sometimes with local and tumescent anesthesia, and this can be a starting point for beginners. It is important to approach the standard of care for one’s community and all surgeons should obtain hospital privileges or certify an in-office surgery center as soon as they can. The supreme importance is patient safety.
Some younger surgeons, in the beginning, may choose to operate with a procedure chair, dental chair, or procedure table. If a surgeon is serious about cosmetic surgery, there is no substitute for a formal operating table, and these can be purchased refurbished. Having the ability to position patients laterally (airplane) can be of great assistance, especially with older patients with limited neck mobility, which makes intraoperative head positioning difficult ( Fig. 4.2 ). This prevents the surgeon from bending over and working upside down.
An additional item that has become personally indispensable is an operator stool that can be vertically repositioned ( Fig. 4.3 ). Cosmetic facial surgery and especially facelift surgery requires much repositioning of the patient and hence the surgeon must change his or her positions throughout the procedure. I begin in an elevated position but frequently “drop down” to look under the preauricular flaps and other structures. Having an easily adjustable and comfortable stool can facilitate long procedures.
A notable addition here is aimed at younger surgeons. When doctors are young, they can ignore operating posture, stand all day, bend over and slump, and hold their head and neck in awkward positions without problems. Over decades, these nonergonomic positions and habits catch up with many surgeons and can prematurely end a fruitful career. Cervical and back problems are common occupational disabilities in surgeons. Also many surgeons develop kyphosis from standing with poor posture for long hours. It is imperative to avoid these bad habits before they wreak havoc. I implore all young surgeons to force themselves to sit during surgery and to pay attention to their posture and ergonomics. Because surgeons are lost in the procedure, it is best if observant staff performs “posture checks” on a regular basis. In addition, performing stretching and weight exercises can strengthen muscles and improve flexibility. I personally also feel that moderate weight training is valuable for surgical endurance. Shoulder shrugs with dumbbells or barbells assist the upper body and shoulder girdle and lateral dumbbell extensions and seated presses are also useful. Lateral pulldowns can also be valuable. Stretching is very important because many surgeons lose flexibility from years of standing, bending, and hunching. One of my favorite stretches is to stand facing a wall and hold an ear to the wall as if trying to listen to the next room. While doing this, the opposite shoulder is brought close to the wall to enhance the stretch. This is done for several sets of 15-second stretches for both sides. Sitting on a chair and allowing the neck to extend as far back as possible over 30 seconds is a useful stretching exercise. Finally, simple toe touches and seated head-to-knee stretches will assist in flexibility. The goal of the exercise is not only to strengthen the muscles of the neck, spine, and shoulder girdle, but to apply stretching forces opposite to those that occur when hunching over performing surgery. If you love what you do, you want to do it for a long time. Maintaining a physical regimen of weight and cardiovascular training throughout your life will allow you to have more surgical endurance with fewer work-related physical disabilities.
Although many specialized instruments exist specifically for rhytidectomy, in reality the procedure can be performed with relatively basic surgical instruments most surgeons already have in their offices ( Fig. 4.4 ).