As otolaryngological surgeons well know, many facial cosmetic and reconstructive procedures can be safely and successfully performed without the use of a hospital operating room. Patients seeking elective cosmetic work generally know it too and are accustomed to undergoing desired procedures in smaller and more specialized outpatient settings. This often means an ambulatory surgical center (ASC).
Explore This IssueSeptember 2021
Increasingly, however, plastic surgeons are cutting out the middleman and establishing their own on-site surgical facility designed for cosmetic or reconstructive procedures on low-risk patients. A reported uptick in the number of in-office surgical procedure rooms can be partially traced to study findings that seem to support the safety of office-based anesthesia (OBA) (Curr Opin Anaesthesiol. 2019;32:749-755). Once considered the exclusive purview of the hospital, OBA is a primary focus of the safety standards dictated by the regulatory and accrediting bodies that oversee office-based surgical facilities and practices across the U.S.
However, there are other compelling reasons why office-based surgery has become more popular: It’s a comfortable alternative for patients, and it gives practitioners control over everything from staffing to sutures.
Bringing It Home
The complexity of setting up an in-office surgical area depends largely on the surgeon’s intended scope of procedures. For Jacob D. Steiger, MD, owner of Steiger Facial Plastic Surgery in Boca Raton, Fla., that intention included a fully equipped surgical center in which, technically, no procedure was off the table. He now calls it the best decision he ever made, though he wasn’t so sure at first.
“I certainly questioned my decision at the beginning because I could have operated at a surgical center across the street, and it would have been a lot easier. There are a lot of expenses involved in opening up your own surgical center,” he said. “Obviously, you have to build up to the point where you can do this.” Those expenses vary widely depending on whether it’s a new space or a buildout, and which equipment needs to be purchased. Staffing can also be a major expense. At Dr. Steiger’s center, it takes a staff of 15 to supply the needed care and support to administer surgeries four days per week.
Given the considerable upfront investment of an in-office facility, the question arises: Why do it? According to Peter Vila, MD, of Vila Facial Plastic Surgery in Northern California’s Marin County, the answer doesn’t necessarily involve profit seeking. Dr. Vila opened his private practice in 2020 and currently performs only smaller cosmetic procedures, such as upper blepharoplasty, in his office using local anesthesia with oral sedation. He plans, however, to build an in-office surgical practice that includes a fully equipped surgical facility.
“The decision isn’t so much from a business standpoint because it isn’t really profit-driven to have an OR,” he said. “I think the main benefit is that you always have access to it. Whenever you work with a hospital, there are difficulties in scheduling. With an ambulatory surgery center, it’s better, but with your own facility, you run the schedule.”
Other otolaryngologists who have made the move echo Dr. Vila’s sentiment. Diana Ponsky, MD, of Ponsky Facial Plastic Surgery, LLC, worked for University Hospitals Cleveland Medical Center for 13 years before she opened her office-based surgical facility in the suburb of Beachwood, Ohio, four years ago. With young children at home, Dr. Ponsky values the ability to flex her schedule to accommodate their needs. At the hospital, she recalls having to involve “five people and 10 forms” just to make the needed changes.
Overall, the ability to call the shots is probably the greatest draw. “I loved working for the university, but one thing that became increasingly clear was the need for autonomy,” Dr. Ponsky emphasized. “In a big university setting it was hard for us to even, say, biopsy a mole in the office because we didn’t have the proper setup, the necessary help—we only had medical assistants, who aren’t always comfortable assisting a doctor with a procedure. Also, not all of the instruments were necessarily there because every facility is different.”
Another compelling reason to bring more surgical procedures in-house: Many patients prefer it. For some, the primary concern is avoiding the potential for infection from receiving care at a heavily populated hospital or ASC (see “The COVID Bump,” below). Others simply gravitate toward being tended to in a smaller, more private setting when receiving their rhinoplasties, face lifts, and reconstructive procedures. They know they’re less likely to “get lost in the shuffle” of a busy hospital caring for multiple patients 24/7. “In our office-based center, we do one surgery at a time on one patient at a time, with everything geared to that patient,” said Dr. Steiger. “I believe that lots of people prefer to have that nice environment and receive a more personal experience in a location and from people with whom they are already familiar.”
Patients may also appreciate the simpler fee structure of office-based medical services. A patient who has been to a hospital or ASC will typically be charged separately for facility and anesthesiologist fees and may even need to grapple with insurance companies over individual items. With office-based surgery, there is one service provider and one bill. “My patients don’t get charged a facility fee for office-based procedures. We will charge an extra $50 if we need to use special sutures or something like that, but that’s nowhere near what an ASC would charge,” said Dr. Ponsky. “My patients are grateful for the transparency—they know what codes we use, and they know upfront what the insurance might pay.”
However, office-based surgery isn’t for all patients. Although cosmetic patients are usually young and healthy, all patients need to be assessed prior to surgery. “We follow the guidelines of the Academy of Anesthesiology,” said Dr. Steiger. “Males over 40 and females over 45 require clearance from a physician, an EKG, and whatever else the physician might feel is necessary to ensure that patients are healthy enough to undergo anesthesia.” In-office surgical patients are advised in advance as to any unexpected events, such as reaction to anesthesia or excessive bleeding, and what actions would be taken in those events.
“If you are comfortable, the patient is usually comfortable,” said Annette Pham, MD, a partner physician at Metro ENT and Facial Plastic Surgery in Rockville, Md., who has practiced otolaryngological medicine for almost 20 years and started performing in-office sinus surgeries in 2017. “Spend time explaining to the patient what’s involved, because oftentimes the most anxiety-provoking thing for them is not knowing what’s going to happen.”
Scope of Practice
The specific procedures that can be performed in office-based facial surgery are driven by the requirements and regulations established by the state in which the surgeon practices and/or an accrediting body that works with the state. Not surprisingly, rules stipulating the allowable type of anesthesia, maximum hours of surgery per day, staffing and insurance requirements, and types of drugs dispensed vary throughout the country. “What defines office-based surgery could be different in New York than it is in Texas,” pointed out Dr. Steiger. “Here in Florida, with cosmetic surgery, you have to have an accreditation. We’re an accredited AAAASF facility. We have the space, the supplies, and the equipment, but we’re not a hospital, so we’re considered an office-based surgery. We do nose jobs, face lifts, laser, and upper eyelid and lower eyelid surgery.”
Doctors tend to do the things that they’ve been taught and not stray from them—often for very valid reasons—but you can do plenty of procedures, even face lifts, under local anesthesia with oral sedation. —Peter Vila, MD
Dr. Steiger’s practice is accredited by the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), established in 1980. In 1992, the AAAASF became an accrediting body for all American Board of Medical Specialties board-certified surgical specialties’ office-based surgery units. Strongly aligned with the 1994 American College of Surgeons’ Guidelines for Optimal Ambulatory Surgical Care and Office-based Surgery , the AAAASF targets its requirements to three separate classes of service, based on tiered classifications of anesthesia: 1) Local or topical anesthesia; 2) intravenous or parenteral sedation, regional anesthesia, and analgesia or dissociative drugs without the use of intubation or inhalation general anesthesia; and 3) both of the above but with use of intubation and/or inhalation anesthesia administered by an anesthesiologist or certified registered nurse anesthetist.
In 1996, with the involvement of the AAAASF, California became the first state to mandate accreditation for all outpatient facilities that administer sedation or general anesthesia. Subsequent varying laws and regulations guiding office-based surgery units were adopted by additional states such as Florida, Georgia, New Jersey, Pennsylvania, and Texas. As an AAAASF-accredited practice, Dr. Steiger’s facility has the latitude and capability to offer general anesthesia, although he opts for IV sedation with no intubation. “The anesthesiologists who come to my office are the same anesthesiologists who work at the hospital,” he said. “As an accredited practice, we’re held to the same high standards.”
In her Ohio-based practice, Dr. Ponsky has found that a combination of local anesthetic and oral sedation is all she needs for most of her procedures. “There are traveling anesthesiologists who would be willing to work with me in the office, but I haven’t needed to use those, and it’s a whole different level of regulation and accreditation that I don’t need for a majority of select procedures,” she said. “You just have to know your patient and prep them ahead of time.” That said, Dr. Ponsky does go to an ASC or hospital to operate on her patients who she knows will require general anesthesia.
Like Dr. Ponsky, Dr. Pham performs office-based surgeries using solely local anesthesia and optional oral sedation. “It’s important for the surgeon to be aware of what constitutes conscious sedation in their state regulations and follow standard monitoring precautions set forth by the state’s medical board. But otherwise, if there’s no conscious sedation or even IV sedation, the facility isn’t subject to any specific accreditation needs—just normal OSHA rules and regulations,” she noted. Her in-office procedure room is set up expressly for the purpose of performing surgical procedures and includes specialized equipment, a chair that can be set in a supine position, and an exhaust system to enhance circulation.
The Future of In-Office Surgery
Cosmetic surgery offices are designed to provide a limited number of services to mostly healthy patients. “We’re geared toward one thing, and the select procedures I do, I do over and over and over again,” said Dr. Steiger. “I think this is what allows us to provide not only a better experience, but better care, for our patients.”
My patients are grateful for the transparency—they know what codes we use, and they know upfront what the insurance might pay. —Diana Ponsky, MD
As the trend toward more in-office surgery grows, proponents of the practice expect to see pushback from those who prefer the status quo. “Doctors tend to do the things that they’ve been taught and not stray from them—often for very valid reasons—but the fact is that you can do plenty of procedures, even face lifts, under local anesthesia with oral sedation,” said Dr. Vila. “People who have never done that might think, ‘Oh my God, that’s crazy,’ but I can tell you from firsthand experience that it is possible to do it and keep the patient comfortable. I think there’s a whole wide-open field out there.”
Others who may not be keen on the trend of in-office surgical options are hospitals. “I believe they tend to push toward non-office-based procedures for monetary reasons, because they can get a facility fee and anesthesia fee out of it, and that’s sad because hospital-based procedures aren’t always the most convenient thing for a patient,” said Dr. Ponsky. “No one wants to take a day off work for surgery and have their family take a day off for a simple procedure that can be done in an office setting. That’s why I think office-based procedures are going to increase in the future.”
Dr. Pham views the issue from a historical perspective, noting that when nasal and sinus surgeries first came about, everything was done in the office. “Then somewhere along the line, we transitioned to doing everything in the OR. Now, the pendulum is swinging back,” she said. “I think finding the balance in approaches is key—matching the patient to the appropriate procedure and approach.”
Linda Kossoff is a freelance medical writer based in Woodland Hills, Calif.