Opinion | From Botched Buttocks to Botulism

Long ago, when I was a medical rookie on rounds and pre-op antibiotics were not yet routine, I saw a patient with an infected face-lift. Once beyond earshot, our attending mused about possible slip-ups in her surgical asepsis. I listened, of course, but also couldn’t help thinking: “What a shame. She was looking for beauty. Instead she got this?”

Thankfully, the patient soon improved. Her gram stain showed grape-like clusters of cocci, then antibiotics were dripped in her veins, and her angry incisions faded and healed.

Fast forward several decades, and what a difference. Today, no seasoned plastic surgeon would omit prophylactic armor against Staph aureus, the world’s most common post-op invader. But for patients seeking beauty at a bargain, a global market in aesthetic procedures sometimes delivers far worse harm.

Take, for example, disfiguring, hard-to-treat infections due to atypical mycobacteria. Or look at the recent outbreak of botulism in at least 60 medical customers in Turkey, several of whom, after receiving intra-gastric injections of botulinum neurotoxin meant to shrink their stomachs, landed in ICUs, struggling to breathe.

Whatever you may think about bodily obsession or dubious ways to lose weight, simply saying caveat emptor or “let the buyer beware” (translation: do your homework) is not enough to protect modern consumers.

The Appetite for Altered Bodies

Not surprisingly, the global quest for beauty translates to a big business predicted to grow by nearly 10% per year through 2030.

Current numbers back this up. The latest annual statistics from the International Society of Aesthetic Plastic Surgery (ISAPS) reveal about a 19% jump in both surgical and non-surgical procedures in 2021. What were the most desired cosmetic revamps?

In 2021, liposuction surpassed breast augmentation as the most common operation, followed by eyelid surgery, rhinoplasty, and tummy tucks, while a 4-year trend confirmed the rapidly growing popularity of buttock lifts and buttock augmentation. The top five non-surgical procedures were injections of botulinum neurotoxin and hyaluronic acid (often used as a facial filler), hair removal, skin tightening, and fat reduction.

Now, let me offer a snapshot of foreign medical tourism sites from the ISAPS report. Turkey, Colombia, Mexico, and Thailand led the list in 2021, but there’s a caveat. Although ISAPS’s 5,600 members reside in 117 countries, their official roster includes only “the world’s most respected aesthetic and reconstructive surgeons.”

In other words, it is anyone’s guess who else is attracting medical tourists and performing cosmetic procedures — and in what settings.

Notably, cosmetic procedures performed abroad aren’t alone in posing risks to unwary patients. In 2021, U.S. plastic surgeons performed roughly 60,000 Brazilian butt lifts (BBLs) despite growing evidence that they are sometimes complicated by life-threatening fat emboli. As Harvard University’s Samuel Lin, MD, stated in a recent interview: “The mortality rate of BBL is estimated to be as high in one in 3,000… greater than [for] any other [form of] cosmetic surgery. Any patient considering a BBL should be informed of the risk of death from this procedure.”

Alarming Techniques and Infections

One challenge for many U.S. doctors is grasping just how many sub rosa procedures occur in our own backyards. I’m no exception. I still remember my amazement when, in 2008, 8 women in New Jersey developed ugly, burrowing infections after unlicensed providers injected their buttocks with substances ranging from silicone to so-called “bio-gels.” Eventually, Nocardia proved the common culprit. The patients required multiple antibiotics and debridements and suffered significant scarring.

More often over the last 2 decades, clusters of infections due to rapid-growing mycobacteria — specifically M. chelonae, M. fortuitum, and M. abscessus — have plagued patients undergoing overseas breast augmentation, abdominoplasty, liposuction, and buttock lifts, especially in the Dominican Republic. Likely contributing factors? Because rapid-growing mycobacteria form biofilms and resist disinfectants, contaminated tap water and inadequate sterilization of surgical instruments are probably to blame.

Another recent article aggregated data on 214 American residents who were mainly female, middle-age, and Hispanic. These patients underwent aesthetic operations in 13 foreign countries, then returned to the U.S. with serious infections and other complications. Along with prolonged medical treatment, roughly half of the cohort required costly re-hospitalizations and/or follow-up surgery.

Even more dire consequences including necrotizing fasciitis, gas gangrene, and sepsis can follow liposuction, which typically involves infiltrating multiple liters of (potentially contaminated) wetting solution. In a 5-year review from Germany, 2,300 questionnaires completed by intensive care specialists, pathologists, and forensic medicine experts uncovered 72 such events and 23 liposuction-associated deaths.

Finally, Finnish researchers have shown that dangerous, multi-drug resistant bacteria are far more likely to accompany people returning from an overseas hospital stay in a tropical as opposed to a temperate locale.

Educating Consumers

As much as we strive to reduce them, a certain percentage of patients will always experience surgical-site infections. But people seeking low-cost, cosmetic operations in overseas settings are especially vulnerable. Not only do such tourists fly blind because they rarely speak with a doctor before scheduling their trips and promotional websites minimize risks, but also, in many cases they are placing faith in a system with virtually no health-quality data.

Let’s be honest: Who among us with medical knowledge would want a family member to buy an all-inclusive “vacation package” that includes surgery?

An excellent briefing paper on cosmetic medical tourism is available from the American Society of Plastic Surgeons. In addition, perhaps the time has come to talk about surgical asepsis and present contemporary case-studies in school health classes, public libraries, and other community settings. If so, how about adding some medically-graphic photos?

I can only speak for myself, but if I were weighing the pros and cons of flying to a far-off land to enhance my looks, one glance at a post-op body part ravaged by cellulitis, sinus tracts, and scars would make me think twice.

Claire Panosian Dunavan, MD, is a professor of medicine and infectious diseases at the David Geffen School of Medicine at UCLA and a past-president of the American Society of Tropical Medicine and Hygiene. You can read more of her writing in the “Of Parasites and Plagues” column.