How to build a body-contouring practice for bariatric surgery patients

Iis estimated that more than 60% of Americans over the age of 20 are overweight, and many of these individuals would be properly classified as morbidly obese.1 Bariatric surgery, the surgical treatment for morbid obesity, has grown explosively during the past several years. An estimated 144,000 bariatric procedures were performed in 2004, an increase from only 67,000 in 2002. Projections for bariatric surgery show growth at an incredible 20% per year; more than 172,000 procedures may be performed in 2005.2

Similarly, plastic surgeons have seen an impressive increase in the number of patients who request body-contouring procedures following significant weight loss. Most, if not all, bariatric patients are left with hanging skin, hygiene problems, ill-fitting clothing, and difficulty exercising or even performing normal daily activities.

More than 106,000 body-contouring procedures were performed in 2004, an increase of more than 77% over the past 5years, according to the American Society of Plastic Surgeons (ASPS).3 More than half of these (56,000) followed massive weight loss. There were 43 times more lower-body lifts and 30 times more upper-arm lifts performed in 2004 compared to 2000. Thigh lifts increased by 45%, and lower-body lifts by 72% in 2004 compared to 2003.

This growth will continue to be driven by the increasing number of patients undergoing bariatric surgery. Therefore, it is imperative that plastic surgeons prepare themselves for the fastest-growing segment of our patient population.

Over the past 5 years, my own postbariatric body-contouring practice has grown to the point that 50% of my patients receive this complex, challenging, and extremely rewarding procedure. My goal is to familiarize plastic surgeons with the tools necessary for integrating bariatric patients into their current patient populations, and, if desired, to develop this highly specialized area of plastic surgery as a focus of their practice.


Step One: Cultivate Referrals

As bariatric surgery increases in popularity, it is being performed by more and more general surgeons. Determine who is performing these procedures in your community, and meet with them to express your interest in caring for these patients after surgery.

Bariatric patients almost always turn to their surgeon as a primary resource in their search for the right plastic surgeon. Perhaps they attend support-group meetings for postbariatric patients, at which you might be invited to speak. Perhaps the local bariatric surgeons would consider placing your business cards or practice brochures in their waiting rooms.

In addition, many bariatric surgeons have Web sites, and most are willing to exchange links with a plastic surgeon dedicated to improving their patients’ quality of life. It is important that you convey to the bariatric surgeons your genuine interest in postbariatric body contouring and the exceptional care and customer service you will deliver to their patients. Of course, you must back up these pledges in your practice.

Bariatric surgery encompasses a relatively small community, and patients interact with one another frequently at their physicians’ offices, online, and at support-group meetings. Another primary resource for those searching for a plastic surgeon is word-of-mouth advertising by your patients. Remember: What you do and say to one patient will likely be related to many!

Other potential referral sources include local internists, radiologists specializing in mammography (and mammography centers in general), obstetricians, and gynecologists. These professionals come into contact with numerous postbariatric patients who inquire about plastic surgeons.


Step Two: The Insurance Decision

The decision of whether or not to accept insurance for these procedures is a personal one that is based largely on your current status as an insurance provider and your current patient population. I have never been an insurance provider, and I do not accept insurance for any procedure that I perform. I have found that the level of quality and the intensity of care that I insist upon cannot be adequately delivered for the amounts being paid by the insurance companies.

I do offer to provide my patients chart documents, such as surgery reports, health histories, physical examinations, and payment receipts, so that they may seek reimbursement directly from their insurance companies. Many of my patients have received insurance reimbursement for the full cost of the procedures performed under my care.

Even though I am not a contracted insurance provider, I do not have to turn away insured body-contouring patients who wish to have a concurrent incisional hernia repair that is covered by insurance. Several general surgeons in my community and I have developed a relationship in which the surgeon accepts insurance for the hernia repair and the patient bears the cost of my portion of the procedure. The patient’s insurance usually pays for an overnight stay in the hospital when the general surgeon determines that this is necessary. This has worked extremely well in my practice.

I perform this type of combination procedure approximately three to four times per month, and it has worked extremely well. In the usual sequence of events under this arrangement, I raise the abdominoplasty flap, the general surgeon performs the hernia repair, and I perform the plastic surgery. This goes so smoothly that the operation takes no more time than if I had repaired the hernia  myself.


Step Three: Public Speaking

In addition to speaking at support-group meetings, you might also consider speaking at your local hospitals. If you express an interest to the hospitals’ medical staffs or marketing departments, many of them will invite you to speak in their conference rooms. They will usually perform the marketing and advertising for the events, and they may even provide refreshments. All you will need to do is dress professionally and give a great presentation.

I recommend bringing a staff member or two with you to your speaking engagements. If your presentations are well-received, you will likely be inundated with “personal” questions after the meetings. If you are surrounded by too many people, many patients will get discouraged and leave. But if your patient coordinator and nurse accompany you, they can answer many of the prospective patients’ questions, hand out your practice literature, and narrate a “tour” through your albums of before-and-after photos.

With the increasing popularity of television shows featuring plastic surgery, you may be invited to participate in one. A producer may contact your office and ask you to provide a patient to follow from the preoperative consultation through the postoperative recovery. When choosing an upcoming surgery patient to ask to participate, remember that this patient will ultimately represent your practice, and that the patient—not you—will generally be the focus of the segment.

You should always insist that you have the right to use any televised material for your own marketing or Web site use. Well before the day of the surgery, ask the producer if you will be required to sign a contract. The morning of surgery is hectic enough with a film crew in your operating room, and it is certainly not the time to be reviewing a contract! If there is a contract, read it thoroughly before you sign it, and do not hesitate to cross out or change any conditions that you find unacceptable.

Another word of caution: I firmly believe that you should never be asked to contribute to any type of “production cost” for a television broadcast. Many phone calls from television producers are actually sales pitches. So before you get too excited about being asked to participate in a television show, find out the exact details of the proposal. I have instructed my staff to reply to all television producers that I do not contribute to production costs, and that if they still wish to speak with me, they should email or fax me the details of their proposal. In my opinion, a Board-certified plastic surgeon should not pay to be featured on television. If you are asked to contribute to the costs in any way, you should immediately decline to participate.


Step Four: Your Greatest Asset

Nothing works for you 24 hours per day, 7 days per week, as well as your own practice Web site. This seems obvious now, but as little as 5 years ago, very few plastic surgeons had their own Web sites. This is your forum to speak your mind and to expound on any topic you wish. After speaking with thousands of patients, the clear message I have gleaned is that patients respect and prefer Web sites that offer a great deal of content and factual information.

Avoid turning your Web site into an infomercial about yourself. Remember, the initial visit to your Web site will be the first encounter many patients have with you and your office, and you only get one chance to make a good first impression! It is certainly the correct forum to list your procedures, accomplishments, educational background, and Board certification, but avoid using the terms “best,” “first,” and “only,” because they are probably not true.

Selecting an address for your practice Web site is a very important decision, and I recommend that you use your name, the name of your practice, your state or city name, or another easily recognizable URL. The easier it is for patients to remember your Web address, the more visitors you will receive.

Examples of appropriate Web site addresses are:

www.drjohndoe.com;

www.drdoe.com;

www.johndoemd.com;

www.doeplasticsurgery.com; and

www.doecosmeticsurgerycenter.com.

You can visit www.networksolutions.com to determine whether your favorite Web site names are available, to register them, and to prevent anyone else from using them.

Once you have chosen an address, the next step is to hire a Web site designer to work with you to complete the project. I believe that the key ingredients to a practice Web site are the following:

• a professional photograph of you (and possibly also your staff);

• your office telephone number;

• whether or not you offer complimentary consultations;

• a brief description of your most common procedures;

• a selection of preoperative and postoperative photographs of your most common procedures, with as many different types of patients as possible, including both genders;

• a Health Insurance Portability and Accountability Act of 1996 (HIPAA)– compliant, secure contact email address for online inquiries;

• patient testimonials gathered from your “thank-you” notes and other sources;

• your credentials, including Board certification and society memberships; and

• your address, directions from major highways or landmarks, and a map to your office.

Finally, once your URL has been selected and your Web site is up and running, make sure that all of your practice documents—such as your letterhead, return-address labels, and business cards—contain your Web address. I never let a piece of paper—even my prescription pad—leave my office without my Web address on it.


Step Five: Maximize Your Web Presence

Consider being featured on Web sites that cater to bariatric patients, such as www. obesityhelp.com and www.wlslifestyles. com. For a nominal fee, these sites will list your practice as being one with experience and interest in postbariatric body contouring. These sites receive hundreds of thousands of visits each year from patients seeking information about bariatric resources.

Also invite your patients to post testimonials about you on these sites; this will increase your exposure to the bariatric population and convey more personal details about you and your practice from the patient’s point of view. Further­more, these sites periodically host online chat sessions, and you may serve as the plastic surgery expert if you wish to participate.


Step Six: Educate Yourself

Many plastic surgeons never encountered a single bariatric patient during their residencies, but now these patients are coming in for consultations 5 days per week! It is essential that you gain a proper understanding of this subject, because, for a given procedure, the bariatric patient is not the same as the nonbariatric patient of similar weight.

To increase your knowledge, I strongly recommend that you attend an ASPS-sponsored course on postbariatric body contouring, as well as classes on this subject at its regional and national meetings. You may purchase videotapes or DVDs of the actual procedures that are extremely helpful in preparing for surgery, and a search of plastic surgery journals will provide a wealth of information.


Step Seven: Tailor Your Practice

Once you have attracted bariatric patients to your practice, you must deliver what they expect: professionalism, courtesy, honesty, a dedication to postbariatric body contouring, and great results. This starts at the front desk. The person who answers your phone is, in many cases, the most important individual in your office. If she is not courteous and helpful to the postbariatric patient, you will never have the opportunity to meet that patient, much less perform surgery. I recommend that you thoroughly review the subject with your staff and reinforce that these patients are to be welcomed with open arms by everyone in your practice who represents you during phone calls, by email messages, or in person.

Bariatric patients’ needs are somewhat specialized. For example, many will be vitamin- and protein-deficient. I require my patients to take a protein supplement from 2weeks before to 4weeks after surgery. I also require patients to take a certain vitamin formula for the same 6weeks. Rather than give them the information regarding these products and hope that they purchase them, I actually include their cost in their surgical fee quotation. I also sell these products directly to the public from my office, along with products for topical scar improvement and postoperative bruising and swelling reduction.

The management of bariatric patients also differs from the management of other patients. Using an orthopedic bed with a trapeze after surgery works wonders, allowing body-contouring patients to reposition themselves in bed and to get in and out of bed.

Many bariatric patients have difficulty swallowing large antibiotic or narcotic pills. Therefore, I always offer to prescribe the liquid form of the same medication. Also, because bariatric patients are sensitive to intravenous dextrose, I avoid any dextrose in the postoperative-maintenance fluids. Be­cause many patients have a small gastric pouch, I also premedicate all patients with the antiemetic ondansetron hydrochloride, at first intravenously and then with the oral dissolving tablet. By individualizing the care of each patient and showing all patients that you are aware of and sensitive to the special circumstances of their condition, you will become well-respected and recommended by this patient population.


The Payoff

I also recommend including literature specific to the bariatric patient in the welcome packet that you give to each prospective patient at the beginning of your consultation. My packet includes a single sheet that contains my background and résumé, a single sheet titled “About Our Office,” an ASPS brochure titled Body Contouring After Major Weight Loss, literature regarding the vitamins and other products available in my office, and my own CD-ROM of several talks I have given at national and regional meetings for postoperative bariatric patients.

The quest to build a postbariatric body-contouring practice takes time, energy, surgical skill, and, most of all, dedication to these procedures and to these patients. These operations are some of the most difficult that we perform as plastic surgeons, and the postoperative period is lengthy and requires intensive, frequent office visits. However, the relationships that you develop with these patients will be some of the most rewarding of your career, because you get to know these patients very well, and you change their lives forever. n

Don R. Revis, Jr, MD, FACS, is a double-Board-certified plastic surgeon in private practice in Fort Lauderdale, Fla. He is a member of the American Society of Plastic Surgeons and the American Society for Aesthetic Plastic Surgery. His Web site, www.southfloridaplasticsurgery.com, receives more than 75,000 unique visitors per month. He can be reached at (954)  630-2009 or [email protected]


R
eferences

1. Weight-control Information Network. Statistics Related to Overweight and Obesity. Available at: http://win.niddk.nih.gov/statistics/index.htm#preval Accessed June 9, 2005.

2. American Society of Plastic Surgeons. Gastric Bypass Surgery Popularity Leads to Jump in Plastic Surgery Procedures, According to ASPS Statistics. More than 52,000 Body Contouring Procedures Performed for Massive Weight Loss Patients in 2003. Available at http://www.plasticsurgery.org/news_room/press_releases/Gastric-Bypass-Surgery-Popularity-Leads-to-Jump-in-Plastic-Surgery-Procedures.cfm Accessed June 9, 2005.

3. American Society of Plastic Surgeons. 2004 Quick Facts on Cosmetic and Reconstructive Plastic Surgery. Available at: http://[removed]www.plasticsurgery.org/public[/removed]_education/2004statistics.cfm Accessed June 7, 2005.