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erative photographies altered with imaging
software to show an unrealistic result, descriptions of miraculous procedures, or descriptions of
products that do not show their possible adverse
reactions. Another instance of false advertising is
the publication of false entries of one’s curriculum vitae, with internships in institutions or other
titles that the person does not own. It is to be
noted that the duty to inform should extend not
only to the description of the foreseeable and frequent complications but also to clarify those
complications that could have an impact on each
patient based on their situation.
! Attention
Be aware that even disclaimers under the pre-op
and post-op images stating that the result displayed may not be applicable to the case of the
reader are not enough to extinguish liability in
some jurisdictions.
8.2.1.5 Bribery
Bribery is dened as the offering, giving, receiving, or soliciting of any item of value to inuence
the actions of an ofcial or other people in charge
of public or legal duty. Depending on the jurisdiction in which this crime occurs, it will or will
not need the existence of an agreement between
the parties. In Europe, the crime of bribery
between individuals was introduced in 2003. The
prosecution of this crime in Europe has the objective to protect the adequate proceeding of the
market, by guaranteeing the implementation of
the penal code in those cases that a position of
dominance is attained through bribery instead of
fair competence. It is to be noted though that in
Europe the crime of bribery between individuals
is punished in a harsher way than the bribery of a
civil servant.
In the eld of aesthetic surgery, it is not
unheard of someone to accept a gift to code an
aesthetic treatment as a reconstructive one, so it
can be billed to the insurer of the patient. Other
instances of bribery between individuals are the
assistance to congresses and courses paid by the
pharmaceutical industry, which can inuence the
doctor to prescribe more loosely one drug or use
one device over others of similar quality.
8.2.1.6 Money Laundering
In the eld of aesthetic surgery, the most common form of money laundering is self-laundering, in which the perpetrator of the crime of
money laundering is the same person that earned
by any criminal activity the money being laundered. Instances of this crime can be found in
aesthetic surgeons that give speeches or conferences in a foreign country, being paid in cash, or
more frequently aesthetic surgeons that y overseas to perform procedures off the books, receiving cash for their service. This cash crosses our
borders and is laundered through limited liability
companies (or their equivalent in different
jurisdictions).
8.2.1.7 Tax Crimes
Related to the practice of aesthetic surgery, it
consists mainly of tax fraud, as some surgeons do
not code aesthetic procedures as such, so they do
not have to pay the VAT (or its equivalent). This
is applicable in the jurisdictions where those procedures deemed “curative” are VAT-exempt. If
both “curative” and “aesthetic” procedures are
equally taxed in a given jurisdiction, this kind of
exploit poses no benet for a surgeon.
There are other tax crimes, but they do not
relate specically to aesthetic surgery. There is a
growing doctrine in Europe that favors the interpretation that “aesthetic” procedures are a form
of patient care and should also be exempt from
VAT, but this controversy exceeds the scope of
this chapter.
8.2.1.8 Crimes Against Public Health
The strategies and policies of the public health
departments and institutions are based on the
most advanced scientic knowledge available
through all the known disciplines. Public health
is a primarily social endeavor, whose objective is
the improvement of the global health of the population. Through the protection of public health,
the government tries to preserve the safety of its
citizens when they acquire products or services in
the market. The need for government intervention is due to the unfeasibility for the citizens to
know the risks or dangers of a product by themselves, given the extremely complex circum-
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stances in which they are produced and
distributed. There is the widespread notion that
some products that can be found in the market,
even though they are well past their expiring date,
can be administered to a patient. This course of
action, no matter whether it is followed knowingly or not, can be the basis for a criminal
charge. Other crimes against public health are the
usage of products that are not approved in a country by the corresponding public health
institution.
8.2.1.9 Forgery
The motive for the prosecution of forgery is the
preservation of the trustworthiness and the safety
of the judicial proceedings. This kind of criminal
offense has a special consideration because it
damages judicial collective goods, although the
main affected is an individual.
In the practice of aesthetic surgery, the commission of this crime could have the objective of
performing tax fraud or attracting more patients,
by producing false reports stating that a procedure is reconstructive in nature in order to not
have to charge the VAT to the patient or vice
versa, forging the reports so a patient that is to
receive a reconstructive procedure is coded as an
aesthetic one, so you can turn this patient into a
private patient, earning more from the same service. Again, this kind of crime is only protable
for an aesthetic surgeon in legal systems in which
aesthetic surgery is taxed differently.
8.2.1.10 Concealment or Failure
toDisclose
In the Spanish legal system, the citizens must
report the commission of crimes that are public in
nature to the corresponding public authority or its
agents. The matter of interest in the prosecution
of this crime is the preservation of the functions
of the administration of justice.
An aesthetic surgeon can face a criminal
charge for such a crime when they help, without
benet to oneself, the perpetrators or accomplices of a crime to benet from the result of said
crime. In other legal systems, the reception of
benet by the concealing surgeon might not alter
the criminal charge. For instance, a surgeon can
lie knowingly about the lesions that a patient
presents, and by doing so is concealing the effects
of the crime that took place on the patient. It is
considered a crime both in its active course of
action (concealment) and in its passive course of
action (failure to disclose).
The concealment of a criminal by altering his
or her distinctive facial features is a feat only
seen in movies and thus falls outside the scope of
this chapter.
! Attention
Whenever you are served a judicial citation
against you or your practice, contact immediately
your insurance provider (when appropriate) and
your attorney/solicitor, and let them guide you
through the process.
8.3 Civil Wrongs andInformed
Consent
Civil law is the body of law that relates to civil
wrongs, property disputes, and rights and duties
of persons (be them legal or natural) in a society.
How civil law is articulated depends on the legal
system to which it belongs. The most widespread
systems in which some type of civil law is identiable are the Common Law system (as are the
legal systems of the United States or the United
Kingdom) and the Civil Law system derived
from the Corpus Juris Civilis, or “Coded Law”
(as are the legal systems of Spain, France, or
Germany). The various laws under the civil law
of the Common Law system and the topics that
concern the civil law of the Coded Law system
can be summarized in two kinds of civil liability:
contractual liability, or the liability that one
assumes on behalf of another party as a result of
a valid contract, and extra-contractual liability, or
the damage for which a person is responsible and
for which there is not a signed agreement between
the parties, such as damages suffered by someone
due to negligence.
Contractual liability emerges from a contract,
and the violation of such a contract is the civil
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wrong known as “breach of contract,” whereas
extra-contractual liability emerges from a person’s actions or omissions, and when those are
wrongful, they are known as “torts” [4].
8.3.1 Tort andBreach ofContract
The torts or extra-contractual civil wrongs that
most directly concern the practice of aesthetic
surgery are negligence, be it in the form of negligent iniction of emotional distress, negligent
iniction of personal injury, or cases of product
liability, for instance, due to products marketed
or sold by you in your ofce.
Regardless of the type of injury, for a negligence case to hold water, it should prove rst that
the plaintiff was owed a duty of care (as a doctor
owes a patient under his or her responsibility);
second that there was a breach of that duty, i.e.,
when the action performed is under the standards
of the profession in that particular case, against
the “lex artis ad hoc”; third that the plaintiff suffered damage as a result of that breach; and fourth
that the damage was immediate to the negligent
act, which means that it was caused by it.
There are other types of torts, but they do not
relate specically to the practice of aesthetic surgery, and therefore it is not the place to discuss
them.
On the other hand, breach of contract is a civil
wrong that does relate to the practice of aesthetic
surgery, particularly the understanding of the
terms of the contract reached between the surgeon and the patient that is going to be the subject
of surgery. The main controversy in contract law
that should concern us is the kind of warranty
that the patient understands from what one
explains during the interview, from the images
that are shown to them, from what is stated in the
informed consent or the interview transcript, or
from the advertising of your practice. These are
usually considered sources of contractual liability in most legal systems, and a wary surgeon
should avoid generating an express warranty of a
result through them, as it may be enforceable in
their jurisdiction [5].
Pearls and Pitfalls
Providing due diligence, a conservative marketing strategy, and a balanced informed consent are
crucial to prevent civil liability lawsuits.
8.3.2 The Informed Consent
The modern concept of “informed consent” was
born in the mid-twentieth century, but some practices associated with it predate the concept name
in medical history, such as seeking that the patient
understands the proposed therapeutic course, that
their permission to initiate such therapeutic
course is requested, and that more than one
option is presented to the patient, letting them
choose without compelling them to pick one over
another.
These practices have been integrated into a
document that is usually presented to patients
and that they are instructed to read. Nevertheless,
written informed consent is not always necessary,
such is the case in emergencies or in minor procedures and physical exploration, where implied
consent or verbal consent may sufce, respectively. When written consent is needed though,
one must not neglect the content of the interview
with the patient. It is an opportunity to build a
good rapport and a trusting relationship, as well
as clarify the most obscure complications of the
proposed operation.
The informed consent is the expression of
the ethical principle of autonomy, by which
the patient is given both responsibility and
agency over his or her treatment. Although
patient collaboration is to be pursued, an individual can only provide a valid informed consent when all the following four criteria are
fulfilled:
• She has the information necessary to make an
autonomous decision.
• She is able to understand the information
presented.
• She is able to form a reasonable opinion based
on the possible consequences presented dur-
ing the interview.
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• She can reach a decision without being subjected to coercion or other types of
manipulation.
Depending on the location of your practice,
you will be subject to one or another code of law
or legal precedents. It is advisable to give your
informed consent forms to an experienced attorney to have them proofread before handing them
to patients to avoid undesired liabilities or litigation. The following parts, as depicted in Fig.8.1,
should be included in a balanced informed
consent.
! Attention
Any informed consent signed by a patient that
does not meet any of these criteria is likely to be
nullied, with grievous consequences for your
practice and your personal life.
8.3.2.1 Instructions
Under this heading, one should explain the general objective of informed consent and ask the
patient to read carefully the whole document
before signing. It should be made clear if she
needs to sign all the pages or only the last one,
and it should include a brief overview of the contents of the consent; that is, it should state that
there are complications associated with the procedure, that the patient compliance with the
instructions of the medic is indispensable for a
good outcome, or that there is a disclaimer at the
end of the text.
8.3.2.2 General Information
A brief description of the pathology is given,
which we intend to treat with the procedure.
Known etiologies, pathophysiology, and a
description of how the procedure corrects the
deformity of the patient written in an understandable way constitute this section’s objective.
Schematic images of the steps of the procedure
can be added in this section. However, these
images should be carefully selected in order to
avoid generating an express warranty of result
based on the images depicted. If images are used,
document accurately what it is said about them,
and emphasize their objective in the disclaimer
section, to prevent the generation of such
warranty.
8.3.2.3 Other Options forTreatment
This section is vital to achieving informed consent, independently of the legal system considered. Explaining to the patient in detail the
available therapeutic pathways in a manner that
she can understand is fundamental to enable them
to take responsibility for their healing process.
8.3.2.4 Inherent Risks totheTechnique
Proposed
Every surgery has some risks associated with the
tissues that are manipulated or the complexity of
the technique performed. Some instances of
inherent risks are breastfeeding difculties for
breast reduction or breast lift, contour deformity
or belly-button loss for abdominoplasty, ap loss
ab cd e
Fig. 8.1 Outline of the contents of an adequate informed consent document. The informed consent should be designed
as a reminder for the patient of the conversation held in the interview, not as the primary source of information
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for breast reconstruction with autologous tissues,
capsular contracture or implant rupture for breast
augmentation, and breast reconstruction with
implants.
8.3.2.5 General Risks Associated
withSurgery
Surgery and anesthesia, although considered safe
nowadays, still carry some uncertainty concerning the occurrence of complications. Wound
healing delay and/or scarring, serum buildup,
bleeding and hematoma formation, and surgical
site infection should always be discussed. Fat
necrosis, deep venous thrombosis, and chronic
postoperative pain are to be explained if the risk
for the patient is higher than usual or if the patient
shows concern about them. Alcohol and tobacco
consumption should also be discussed, and it is
mandatory asking the patient to stop smoking
approximately 7 days before surgery and not
resuming smoking again until well after the
wounds have closed (if at all). Concerning
tobacco, the patient must know the associated
wound healing risks and complications, such as
scar widening, altered pigmentation, wound
dehiscence, and wound infection.
8.3.2.6 Secondary Operations
The possible need for a secondary operation,
should one of the stated complications occur, has
to be discussed in the interview and written down
in the informed consent, as it can alter signicantly the decision of the patient. Moreover, if
she is a post-maternity patient, a secondary operation can entail more time apart from her children, which may be unacceptable for her.
8.3.2.7 Patient Compliance
It is advisable to include in the informed consent
all the instructions that have to be followed by the
patient to avoid complications and undesired
results, as well as the indications for wound care
and stitch removal after discharge from the ward.
cation lines can be provided. Email contact
allows for photographic and video follow-up,
while phone contact data is easier to use.
Instructions to be followed before and after each
follow-up interview can also be detailed in this
section.
8.3.2.9 Disclaimer
Here is to be disclosed the intent of the material
given to the patient, usually by summarizing the
content of informed consent. The reach of the
informed consent presented is to be discussed, as
it is not nor should be meant to be an all-inclusive
document. It is advisable to state that some information that you have given verbally in your interview may differ from what is stated in the
informed consent document, based on the facts of
the particular case of the patient or the current
medical knowledge.
8.3.2.10 Acquisition andUse
ofPatient Images
Patient images are often acquired for a number of
reasons, mainly maintaining an adequate patient
record, preventing liability, for academic purposes, and for patient education. With the uprise
of the demand for aesthetic surgery, one new use
for patient images is advertising, be it by means
of physical billboards, newspapers, or magazines
or through websites or social networks. In any
case, whenever patient images are to be taken, it
is advisable to explain to the patient all the
intended uses for those pictures, accompanying
the explanation with a specic informed consent
form, which is to be signed by the patient before
taking the pictures. This informed consent should
include all the possible uses of the pictures of the
patient’s record, the measures that are going to be
taken to ensure her privacy, and it should also
explain the patient the extent of the rights over
those images that she forfeits and give her the
chance of rejecting some of the uses of her
images.
8.3.2.8 Communication andFollow-Up
The follow-up plan after discharge from the ward
and your practice contact information can be
included in the informed consent, to improve
your availability to the patient. Several communi-
Pearls and Pitfalls
Having an opt-out form for each of the uses of
patient images can be the difference between
having unusable images and images that you just
cannot use for advertising.
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8.4 Conclusion
As marketing trends evolve and new legal precedents or laws that are passed increase the complexity of the regulations underlying the
doctor-patient relationship, it is not feasible anymore to keep up with the latest changes in the law
affecting our trade while maintaining a busy
practice. Having a working knowledge of the
applicable law can prevent the most common
legal issues when setting your practice, while
experienced legal counsel is advisable to get
around the more complex pitfalls and to remain
ahead of the changing legal environment.
It is also critical to maintain appropriate
patient selection criteria and not giving in to
competitive pressures. No economic factor
should substitute your clinical judgment when
deciding if a surgical technique is suitable for a
patient or even if that patient is to receive any
kind of treatment. Treat patients with whom
you can establish a good rapport and refuse to
treat those with whom communication is ineffective or whose expectations are unrealistic.
Use the interview to explore the extent of the
concern of the patient about her deformity and
her desire for further pregnancies or breastfeed-
ing. If the proposed surgery is to be performed
soon after childbirth, discuss the expected
recovery time and the possibility of secondary
surgeries and document these in the informed
consent.
Accurate documentation, careful patient
selection, appropriateness of procedure, and
proper informed consent are the keys to running
a successful practice while reducing the likelihood of the unpleasantness of a legal
proceeding.
References
1. Gorney M.Medical malpractice: the carrier’s point of
view. In: Goldwyn R, editor. Unfavorable results in
plastic surgery. Philadelphia: Lippincott Williams &
Wilkins; 2001.
2. Gorney M.The wheel of misfortune: genesis of mal-
practice claims. Clin Plast Surg. 1999;26:15–9.
3. Nora PF, editor. Professional liability/risk manage-
ment: a manual for surgeons. 2nd ed. Chicago: The
Professional Liability Committee, American College
of Surgeons; 1997.
4. Gorney M.Ten years’ experience in aesthetic surgery
malpractice claims. Aesthet Surg J. 2001;21:569–71.
5. Arbesú Gonzalez V. La responsabilidad civil en
el ámbito de la cirugía estética. 1st ed. Madrid:
Dykinson; 2016.
Establishing aPost-maternity
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AlanMatarasso andDarrenM.Smith
9
Take-Home Points
• Combining an abdominoplasty with breast
surgery is becoming increasingly popular, and
the term “mommy makeover” has entered
mainstream parlance.
• It is critical to ensure that each individual procedure is as safe and successful in a combined
operation as if it were to be performed
individually.
• The primary safety concerns for combined
procedures are systemic problems, especially
VTE, rather than local surgical issues, as the
individual procedures are for the most part
operatively isolated from one another.
• It is reasonable to perform combined aesthetic
surgery procedures as long as rigorous planning and execution criteria are met in the preoperative, intraoperative, and postoperative
periods.
A. Matarasso
American Society of Plastic Surgeons, HofstraNorthwell Health System, Hempstead, NY, USA
e-mail: amatarasso@drmatarasso.com
D. M. Smith (*)
Private Practice, New York, NY, USA
e-mail: dmsmith@darrensmithmd.com
9.1 Introduction
Various aesthetic and breast surgery procedures
may reasonably be combined with abdominoplasty. Careful consideration is essential at all
stages of the process for these combined procedures, from preoperative planning to intraoperative technique, and postoperative regimen. There
are several advantages to combined procedures
including reduced cost, convenience, a single
recovery period, and expedited patient gratication (Figs. 9.1, 9.2, and 9.3) [1, 2]. Goldwyn
wrote that these advantages must be weighed
carefully in view of “the patient’s wants, needs,
and understanding” and “the surgeon’s ability,
stamina, and philosophy” [3]. He further advised
that a sufcient number of experienced staff must
be available and “the patient’s place of residence
(the pressure of doing more to save the patient
travel time and expense)” and locally accepted
practices must be accounted for [3]. Goldwyn
further warned, “It is far preferable for the patient
and the surgeon to be successful in each operation on two or, if necessary, three occasions than
to have only partial success in a combined venture” [3]. Byrd also commented on this issue:
“any monetary savings or time advantage is
quickly lost if complications related to the combination are incurred. Consequently, any presumed advantage must be weighed against the
potential for adverse events” [4, 5]. The surgeon
© Springer Nature Switzerland AG 2023
M. Gomes-Ferreira, J. Olivas-Menayo (eds.), Post-maternity Body Changes,
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Fig. 9.1 Above, 31-year-old gravida 2 para 2 prior to breast augmentation and abdominoplasty. Below, shortly postoperatively after breast augmentation and abdominoplasty
must also remember that the opportunity to perform any unexpected or planned revisions is lost
by combining procedures.
To reasonably combine abdominoplasty with
breast surgery, it must be ensured that the entire
operation is as safe as each component procedure
if performed individually. Moreover, the quality
of each individual procedure cannot be compromised. This chapter is intended to explore the
issues facing surgeons as they undertake procedures combining abdominoplasty with breast surgery in the postpartum setting. We will report
ndings from the literature as well as our
experience.
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Fig. 9.2 Above, 33-year-old gravida 3 para 3 before vertical breast reduction, abdominoplasty, and suction lipectomy
of anks. Below, result over 1year after vertical breast reduction, abdominoplasty, and suction lipectomy of anks
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Fig. 9.3 Above, 35-year-old gravida 4 para 4 before
abdominoplasty, suction lipectomy of the arms, back
rolls, and breast augmentation. Below, result greater than
9.2 Methods
We begin by reviewing the literature to elucidate the state of the art in combined abdominoplasty and breast surgery. We then consider the
senior author’s (AM’s) experience with combined abdominoplasty and breast surgery in the
context of our ndings from the literature. We
then offer recommendations for the successful
and safe execution of combined abdominoplasty and breast surgery in the postpartum
patient.
1year after abdominoplasty (highlighting changes of the
exed abdomen), suction lipectomy of the arms, back
rolls, and breast augmentation
9.3 Findings fromtheLiterature
9.3.1 Intra-abdominal or Pelvic
Surgery withConcomitant
Abdominal Contouring:
TheOrigins ofCombined
Abdominoplasty andBreast
Surgery
The practice of performing abdominal reshaping
in conjunction with anatomically proximate
operations such as gynecologic or intra-
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