The 2000s

The 2000s have continued unusually rapid growth and change in plastic surgery. This pace reflected the increasing speed of communication, but many innovations were reactions to decisions made by state and federal governments.

Decreasing Insurance Reimbursement Leads to Increasing Focus on Cosmetic Procedures

By performing more cosmetic surgery and becoming less dependent on insurance payments, plastic surgery remained uniquely independent. By 2005, the most popular procedure of the specialty was the use of injectable substances to address the effects of aging, as patients sought less invasive, simpler operations to reduce wrinkles.

Following the FDA's approval of Botox® in 2002, ASPS members performed an average of 1.1 million such injections a year through 2006.

By the mid-2000s, surgeons were still losing ground on the critical issue of reimbursement. Payment from third-party payers reached such low levels that many established surgeons rejected the premise they could ever again maintain a practice based solely on reimbursement from reconstructive cases.

The national news resounded with stories about the flight of many surgical specialists from specific locales due to the combination of exorbitant malpractice premiums coupled with steadily decreasing insurance reimbursement.

Shift to Proactive Involvement in Politics

If the prolonged controversy over breast implants was not lesson enough, other pressures taught plastic surgeons they could no longer avoid participation in politics. In response to newspaper reports in 1999 on the deaths of 10 patients who underwent cosmetic procedures in the offices of surgeons in Florida, the state's Board of Medicine declared a 90-day moratorium on office-based surgery.

In 2000, the ASPS convened the Task Force on Patient Safety and Office-Based Surgery Facilities to review, among other areas, identification and evaluation of risk factors. The same year the society's Board of Directors amended its bylaws to require that by July 1, 2002, all members performing surgery under anesthesia do so in only accredited, licensed or Medicare-certified surgical facilities.

The ASPS Government Affairs Committee created regional, fly-in meetings to the nation's capitol in 2001 and the Society opened an office in Washington, D.C., in 2004 to increase plastic surgery's visibility and ability to build coalitions on the Hill.

Through necessity and experience, ASPS developed the ability to respond immediately - in any of the 50 states or the nation's capital - to new mandates or regulations unfriendly to plastic surgery and its patients.

During 2002, the Society also began to emphasize participation in advocacy for members by identifying two or three people in every state who could monitor problems and act as the "front people" should they arise. The specialty knew that if was going to be able to continue to serve patients in the future, it had to become more aware of what medical discussions were occurring in the legislature.

One of the themes of both the 90s and 2000s has been the increased need for legislative monitoring of bills that impact the practice of medicine, whether they address scope of practice or physician taxation.

In 2004, New Jersey enacted the first-ever tax on cosmetic surgery. For years government had cut reimbursement for reconstructive procedures, and now it sought to reduce payment for elective procedures - the very thing that had allowed many plastic surgeons to stay in practice and pay their bills.

Over the following months, ASPS led a coalition that successfully blocked similar bills in six other states. Within two years, New Jersey's lawmakers realized that their bill had been ill-advised, and began investigating how to repeal their disappointingly low-revenue tax.

Public Perceptions Improve

In 1996, ASPRS launched the Plastic Surgery Education Campaign - a national public awareness campaign that sought to educate the public on the importance of choosing a plastic surgeon certified by the American Board of Plastic Surgery.

At the time, the Society's leaders could not have envisioned the transformation in public image that plastic surgery would undergo in the following decade thanks to an escalating amount of media attention.

In 2000, W magazine compiled a list of the specialty's 41 "surgery superstars." ASPS members appeared on television, were quoted increasingly in all the major health and beauty magazines, and even provided data for National Geographic.

In 2003, ABC-TV asked ASPS to allow its members to participate in the reality series "Extreme Makeover."

The request raised a substantial ethical debate among plastic surgeons, but ultimately after reviewing the patient selection process of the show, the Society's Executive Committee agreed to cooperate with the producer and network so long as the importance of the doctor-patient relationship was not lost and that the show's patient selection process did not devolve into a contest.

The series' instant popularity opened the floodgates to a flurry of TV shows about plastic surgery, most of which did not live up to the high standards or positive plastic surgery image of "Extreme Makeover."

Not surprisingly, thanks to the combination of magazine coverage, the ASPS public education campaign and the television saturation of shows revolving around plastic surgery, interest in the specialty and what it offered the general public grew exponentially.

In 2003, more than 8.7 million cosmetic procedures were performed, 32 percent more than in 2002. Over the same time period, ASPS members performed 64 percent more procedures involving injectables.

By 2004, 14.8 million plastic surgery procedures were performed in the U.S. And by 2006, that number had risen to 16.2 million.

FDA Approves Reintroduction of Silicone Breast Implants

On Nov. 17, 2006, some 14 years after the start of the moratorium on silicone gel-filled breast implants, the FDA approved the return of silicone implants to the market for general patient use. This was the culmination of an ongoing study and review process that began in the early 90s.

During this period, the FDA also reviewed saline implants, which remained on the market during the moratorium on silicone. In 1999, following the regulatory process laid out years earlier, the FDA called for a review of safety and effectiveness data on saline-filled breast implants.

In 2000, following hearings and clinical study review, the FDA approved the study data submitted by two saline implant manufacturers, recognizing that saline-filled breast implants earned high satisfaction ratings by implant recipients, despite local complications.

Hearings and discussions on the safety of silicone gel-filled breast implants were held throughout the first half of the decade, and in 2005, the FDA granted silicone implants the status of "approvable with conditions."

It would take another year, but finally, at the end of 2006, silicone implants were returned to the market. More than a decade of inquiry, testimony and an expansive body of science all supported the safety of the implants, which will continue to be monitored by clinical studies in the years ahead.

Future Challenges

Plastic surgeons were able to get Congress to support mandatory insurance coverage for breast reconstruction patients in the 90s and are currently working to ensure that reconstructive surgery for treatment of children's deformities will also be covered by insurance plans.

Meanwhile, plastic surgery - always a specialty that has thrived on innovation - continues to push ahead with new clinical breakthroughs, refining current techniques and discovering new ones.

Plastic surgeons are researching methods to reduce surgical scarring and patient recovery time. They are devising new outcomes studies to prove with comprehensive data the quality of life improvements that plastic surgery provides via its vast array of procedures.

And some researchers are now trying to unlock the secrets of the growth-factor environment of the womb, where scarless healing takes place, so that this knowledge can be applied to wounds in children and adults.

The future of plastic surgery continues to unfold, with the promise of amazing new things to come, in the humanitarian pursuit to help patients look and feel their best!