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.”