Aeromedical Considerations for Patient Safety in Aesthetic Medical Tourism
INTRODUCTION: The global rise in aesthetic surgery has led to an increase in aesthetic medical tourism (AMT). As patients pursue surgical interventions abroad, concerns about the elevated complication rates in AMT have emerged. This study explores the complexities of AMT, emphasizing the intersection of plastic surgery and aerospace medicine, to elucidate the incidence of complications, identify associated variables, and introduce aeromedical considerations to proactively enhance patient safety.
METHODS: A comprehensive retrospective observational cohort study was conducted using data spanning 2004 to 2023 from a private plastic surgery practice in Bogota, Colombia. The study included 3367 patients, of whom 26% were international patients. Sociodemographic and clinical variables, flight details, and surgical complications were analyzed. Statistical analyses involved descriptive statistics, odds ratios, and multiple regression analyses.
RESULTS: Of the 865 AMT patients, 75 exhibited complications. Infection and wound dehiscence were the most prevalent; no severe complications or mortality was reported. The study revealed that AMT patients have a higher risk of complications compared to those locally treated (adjusted odds ratio = 4.6; 95% confidence interval = 2.6–8.2). Flight time exceeding 4 h was a factor associated with nonaesthetic complications.
DISCUSSION: This study reveals that AMT is linked to a higher risk of nonaesthetic complications, with flight duration being a significant contributing factor. Despite the increased risk, complication rates for AMT patients did not surpass thresholds reported in the literature; this may be attributed to the safety protocols implemented. Aeromedical considerations played a crucial role in mitigating physiological stress associated with air travel.
Hoyos AE, Ramirez B, Benavides J, Perez Pachon ME, Varela A. Aeromedical considerations for patient safety in aesthetic medical tourism. Aerosp Med Hum Perform. 2024; 95(10):765–770.
Aesthetic surgery is a global phenomenon gaining more acceptance every day and experiencing exponential growth. According to a survey conducted by the International Society of Plastic Surgery, among 1103 plastic surgeons worldwide (out of 25,000 registered surgeons), approximately 14,986,982 surgical procedures were performed globally in 2022. In general, it is estimated that 18% of the patients treated that year were medical tourists.1
Medical tourism refers to the process of seeking medical care outside one’s place of residence, often abroad.2,3 Specifically, aesthetic medical tourism (AMT) refers to this process when individuals travel for aesthetic surgical interventions.4 It is speculated that 14 to 16 million patients worldwide engage in medical tourism, representing an estimated $165.3 billion market in 2023,5 with expectations to reach $3 trillion by 2025.6 However, there are currently no updated and exact data regarding the number of patients undertaking AMT.
Reports suggest that up to 97% of individuals considering aesthetic surgical procedures contemplate having the procedure performed outside their city of residence.7 Primary factors driving engagement in AMT include significantly lower prices abroad (50–90% less),7 enticing packages that integrate travel with cosmetic surgery as a luxurious vacation experience, reduced waiting times,8,9 access to treatments not available in their home country,2,6 and marketing on social media and websites.10,11 Common destinations for AMT include Argentina, Germany, Brazil, Colombia, Spain, and the United States.1
Unfortunately, AMT has demonstrated a higher incidence of complications (infections, surgical wound dehiscence, hematomas, necrosis, bleeding, deformities, and pain) compared to procedures performed locally.7,12,13 Nonetheless, the true incidence of complications associated with AMT remains elusive, primarily due to the absence of accurate data on the annual utilization of these services and the specific occurrence of complications each year.2 Complications arising from AMT are the result of patients not receiving adequate preprocedure guidance, negligent or even absent postoperative follow-up,13,14 and the inherent risks of air travel after a surgical procedure, increasing the risk of deep vein thrombosis, pulmonary embolism, disorientation, fatigue, dehydration, and pain.3,15
There is a notable absence of published reports illustrating the comprehensive management of patients at the intersection of plastic surgery and aerospace medicine or travel medicine. These specialized fields consider the physiological changes during flights and associated risks, yet a thorough exploration of patient management within this overlap remains unaddressed in the existing literature. Moreover, the 12th edition of the International Air Transport Association’s Medical Manual does not provide specific guidelines or recommendations for postoperative plastic surgery patients undertaking commercial air travel. Consequently, the responsibility for offering recommendations during postoperative air travel falls entirely on the plastic surgeon.16
Complications treated in the patient’s home country have a detrimental impact on the local healthcare system that can be attributed to the expenses incurred in addressing events resulting from interventions performed abroad. In effect, infections and such conditions end up affecting the local epidemiology and these complication costs vary from $392 to $150,000.2 Furthermore, these complications often lead to extended hospital stays and the need for multiple surgical interventions and can result in permanent consequences.3,17,18 This study aims to describe AMT in detail, highlight its association with postsurgical complications, and demonstrate the use of aeromedical considerations to proactively prevent the occurrence of severe complications, ensuring acceptable limits for patient safety.
METHODS
A retrospective observational cohort study was conducted, drawing on data obtained from the medical records spanning a 20-yr period. The medical records covered the period from 2004 to 2023.
Subjects
The study population consisted of all patient records from Dr. Alfredo Hoyos’ practice in Bogota, Colombia. All patients underwent presurgical assessments to plan the surgical procedure and other related events, such as travel. They also met the required waiting period in case they were medical tourists who had traveled. After the surgery, all patients received postoperative follow-up and treatment (7 d, 1, 3, and 6 mo).
Materials
The data for this study were extracted from Dr. Alfredo Hoyos’ patient database. However, it was necessary to access the patients’ medical records. The operational database included the following variables:
Sociodemographic information: age, gender, weight, height, body mass index, and the patient’s country of origin.
Clinical information: year of the surgical procedure, surgical procedures performed, duration of surgery, volume of infiltration and suction, use of Blanketrol (water blanket to control body temperature), administration of tranexamic acid, anticoagulation, antibiotic prophylaxis, and surgical complications.
Flight information (only for international patients): flight duration, number of days waiting after arrival for the surgical procedure, number of days waiting postoperatively before returning home, utilization of pre- and postflight anticoagulation, and use of compression stockings.
Statistical Analysis
All records of aesthetic tourism patients were included in the analysis. Descriptive statistics were used to characterize the patient population. To demonstrate associations between various factors and the outcome variable, odds ratios were used. Given that the independent variable (nonaesthetic postsurgical complication) may be influenced by additional variables related to medical tourism and to control biases in a retrospective study, multiple regression analysis was conducted with an adjusted odds ratio (AOR) to illustrate associations. The level of significance for P-values was < 0.05. Jamovi statistical software (The Jamovi project, www.jamovi.org; version 2.5) and Rstudio statistical software (Posit, https://posit.co; version 2023.09.1 + 494) were used for univariate and multivariate analyses.
RESULTS
A total of 3367 patients underwent aesthetic surgical procedures between 2004 and 2023 and were subject to analysis. About 26% (N = 865) were individuals seeking aesthetic surgical procedures and coming from abroad. Out of these 865 patients, 79.2% were women and 75.4% had flights that exceeded 4 h for both arrival and departure. Median age was 36 yr [interquartile range (IQR) = 13], median weight was 65 kg (IQR = 16), median preoperative hemoglobin was 13.9 g · dL−1 (IQR = 1.8), and postoperative hemoglobin it was 10.9 g · dL−1 (IQR = 1.7). Median surgical time was 210 min (IQR = 85) and 91.2% underwent more than one aesthetic surgical procedure simultaneously (see Table I for details). In terms of patients’ countries of origin, the most frequent were the United States (38.6%), Mexico (22.4%), and Venezuela (19.1%) (Fig. 1).
Citation: Aerospace Medicine and Human Performance 95, 10; 10.3357/AMHP.6432.2024
The median number of procedures per patient was 3 (IQR = 2), resulting in a total of 2565 procedures. The most common procedures were liposculpture (33.2%), fat grafting (26.6%), and mastopexy (5.4%). About 86% received thermal protection with Blanketrol, 75% received tranexamic acid to reduce intraoperative blood loss, and 100% received antibiotic and antithrombotic prophylaxis.
A total of 75 patients experienced complications, with 95 reported events. Most common complications included infection (N = 15), dehiscence (N = 15), acute anemia (N = 12), seroma (N = 9), and excess skin (N = 9) (Table II). However, only 54 individuals had complications that were not related to aesthetic complications.
All patients had to wait before surgical intervention. The time was determined by the flight duration: if the flying time was less than 6 h, they had to wait 2 d, but if the flying time was over 6 h, they had to wait 4 d. All subjects received standard postoperative follow-up and care as per institutional guidelines. Patients returning to their places of origin were allowed a minimum hemoglobin level of 8.5 g · dL−1, with the provision that all acute anemias be appropriately corrected. Minimum postoperative ground stay was 8 d, and 100% of individuals employed antiembolic measures such as compression stockings and an additional single dose of low molecular weight heparin on and after the day of the flight. Additionally, all patients reported flying in first class seats for their return-home flights.
Table III presents the outcomes of nonaesthetic complications in relation to whether the patient had international travel for aesthetic medical care. The complication rate was significantly higher in AMT patients compared to locally treated patients [6.24% vs. 0.71%; AOR = 4.6; 95% confidence interval (CI): 2.6–8.2; P < 0.001]. Among women and men, the percentages were 2.37% vs. 0.96% (AOR = 3.1; 95% CI: 1.02–9.4; P = 0.045). Age was a statistically significant variable associated with the occurrence of nonaesthetic complications, although it lacked clinical relevance given the age medians (38.5 yr vs. 32 yr, AOR = 0.97; 95% CI: 0.94–0.99; P = 0.032). Duration of surgery was a statistically significant factor associated with the occurrence of nonaesthetic complications in this study group (AOR = 0.99; 95% CI: 0.98–0.99; P < 0.001).
Table IV illustrates the outcomes of nonaesthetic complications among AMT patients. The nonaesthetic complication rate was significantly higher in international patients who took flights lasting more than 4 h compared to patients who flew for less than 4 h (7.36% vs. 2.81%; AOR = 2.7; 95% CI: 1.1–6.5; P = 0.026). Surgery duration was another statistically significant factor associated with the occurrence of nonaesthetic complications in international patients (AOR = 0.99; 95% CI: 0.98–0.99; P < 0.01).
DISCUSSION
This article provides a different point of view from the current evidence in AMT, going beyond the complications experienced by patients in their home countries or the costs incurred by the healthcare system of the international patients. We were able to observe the incidence of complications in those patients and estimate the risk factors for AMT complications.
Patients involved in AMT exhibit a significantly higher likelihood of experiencing complications compared to locally treated patients (AOR = 4.6). This finding cannot be directly compared to other published studies due to methodological differences.
The overall complication rate for patients involved in AMT was 8.67%. However, when excluding aesthetic complications, this rate decreased to 6.24%. Of note, these values are comparable to the reported complication rate in the literature for body contouring procedures (11.17%) and liposuction (8.36%).19 This observation could be attributed to the plastic surgeon’s experience and the emphasis on patient safety, encompassing both the surgical procedure and postoperative care. Additionally, implementation of aeromedical measures has played a role in mitigating the physiological stress associated with air travel.
Reported rates for infection and wound dehiscence align with the two most reported complications in the literature.4,10,19 However, rates for acute anemia (12.6%) and seromas (9.5%) differed from previous studies. This discrepancy can be attributed to the fact that the present research is based on the entire cohort of patients treated, and these complications were managed promptly in the early postoperative period. In contrast, medical literature typically reports complications from AMT that required medical attention in the patient’s home country. Consequently, complications treated in the destination country and those not necessitating medical care were not considered.
The variable associated with nonaesthetic complications in patients engaged in AMT was flight time exceeding 4 h (AOR = 2.7); this association is likely attributed to the physiological changes the body undergoes when exposed to a cabin environment at an altitude of 8000 ft (2438 m) for an extended period (more than 4 h). These changes encompass lower barometric pressure, leading to a decrease in partial pressure of oxygen and arterial oxygen pressure (55 mmHg; arterial oxygen saturation 90%), low cabin humidity (10–20%), disruption of circadian rhythms (negatively impacting the recovery process), vibration, reduced mobility due to seating (resulting in decreased blood flow in the lower limbs), and the use of clothing and practices that are not suitable for early postoperative recovery.20
Complications reported in this article were characterized as mild to moderate, with no instances of mortality or severe complications such as sepsis, necrosis involving surrounding tissues, deep vein thrombosis, or pulmonary embolism. This favorable outcome can be attributed to the protocols implemented, where patient safety takes precedence. Specifically, during the surgical procedure and in postoperative care, a distinct protocol is used to minimize blood loss, thereby reducing the necessity for blood transfusions,21 minimum invasive procedures are used,22 patients undergoing surgery receive anticoagulation as per risk stratification,23 and prophylactic antibiotics are administered based on clean-contaminated wound classification for these procedures.24 Likewise, aeromedical considerations include delaying the surgical procedure by 2 to 4 d after the international patient’s arrival, depending on the duration of the flight (less or more than 4 h). Patients are required to have a minimum postoperative hemoglobin level of 8.5 g · dL−1 before traveling by air, are provided with preferential class seating on their return flights, and are instructed to use compression stockings, in addition to a pre- and postflight dose of low-molecular-weight heparin to reduce the risk of embolic events.20,25
Our study has certain limitations. First, the inclusion of patients engaged in AMT solely from the clinical practice of a single plastic surgeon means that the results cannot be generalized to all AMT patients worldwide. Second, as a retrospective study based on a pre-established database, it was not feasible to explore new variables of interest, address missing information comprehensively, or conduct interviews or follow-up with the patients.
In conclusion, AMT is indeed associated with a higher incidence of nonaesthetic surgical complications. Variables such as taking flights lasting more than 4 h can have a negative impact on the complication rate. There is a need to develop new protocols to mitigate the risk of nonaesthetic surgical complications in AMT patients. Protocols should concentrate on two phases: the surgical intervention with postoperative care and the physiological stress induced by travel on a pressurized aircraft. Future prospective research in AMT should involve collaboration between aerospace medicine specialists, travel medicine specialists, and plastic surgeons to develop new and better evidence for aeromedical considerations in AMT.
Distribution of home countries among patients seeking aesthetic surgeries. Total patients: 865. Most frequent countries: United States = 334 (38.6%); Mexico = 194 (22.4%); Venezuela = 165 (19.1%); Panama = 30 (3.5%); Spain = 20 (2.3%).
Contributor Notes
Drs. Hoyos and Ramirez contributed equally to this article; dual first authorship.
