Nip/Tuck Vacation by The Sunday Herald 17 July 2005

It’s all sun, sea and breast enlargements for the Brits who travel abroad for a range of cosmetic surgery procedures at bargain basement prices. But how safe is it? Vicky Allan weighs up the pros and cons

FOUR days after her breast enhancement, Annie Law was in the swimming pool at the hotel. There were everyday tasks she still struggled with. On mornings, when she woke, the painkillers had worn off and she struggled to push up from the bed, relying on her boyfriend to lever her into sitting position. On shopping trips, she would turn to him to lift and carry bags. But mostly she was able to behave as normal, relax, sunbathe, go out for dinner. Within a few more days she was taking a fishing boat trip to Teluk Duyung, a Penang beach where monkeys roam the shore. She and her boyfriend would have seemed like any other tourists visiting Malaysia – she even sounds like one now. “Nice beaches. Warm and cheap, cheap, cheap. Food was fantastic. You could eat out for £3. It was really cheap to buy clothes. We came back with loads.” That was not the only thing that was cheap. The entire package for her and her boyfriend – flights, hotel, two weeks’ holiday, boob job – cost £4000. Back home, in the UK, it would have cost that much for the breast enhancement alone.

Law is one of an increasing number of medical tourists going where the sun is hot, the exchange rate is favourable and the surgery bargain basement. The slogan of those who promote this trend is: “First world treatment at third world prices”. It’s a phenomenon that embraces not only those who hop on a plane for a tummy tuck or face-lift, but those traveling for hip replacements, knee replacements, cancer treatment, those who have found themselves lolling on NHS waiting lists or struggling to wring their care out of a stretched home health service. Approximately 50,000 people travel abroad each year from the UK for a range of medical treatments, including cosmetic surgery.

The price differences are significant. In certain developing countries dental, eye and cosmetic surgeries cost anything between a quarter and a third of the price they do here. Indian open-heart surgery costs one tenth of its UK private price. The day was bound to come when people would start to shop around.

Meanwhile, in the developing world, the industry is a growth area so lucrative that there have been government initiatives to promote it. In recent years Thailand, Singapore and Malaysia have led the way (129,318 foreign patients were treated in Malaysia last year) and India is quickly catching up. A recent report by research consultants McKinsey & Co has suggested that by 2012 medical tourism could be worth $2 billion a year to the country and the government is already introducing a special medical visa category for those traveling for long-term treatment. Earlier this year Thomas Cook India announced plans to create sun and surgery packages. These are as yet unavailable and not something that Thomas Cook UK is involved in, but it seems inevitable that before long some major tour operator is going to take the plunge.

In this increasingly privatized world, medical care is less a service provided for the health of a public, but a product to be bought at the best price from whatever stall suits in the global bazaar, and the most expansive area of the market place is cosmetic surgery. There may be a limit to the number of patients requiring a triple heart bypass, but almost every woman in the world might be a possible recipient of a nip, a tuck or a silicone pouch.

Tanya De Villiers has just had the stitches removed from her eyelids. All that’s left is some slight swelling and the small red marks where the stitches have been on her upper lids. I call her in South Africa where she is recovering at her sister’s home. She is, she says, so over the moon with the results, she can’t keep a smile off her face. Despite the bruising, she has already been going to the shops, flashing her purpled lids from beneath her sunglasses and telling anyone who cares to listen, “I’ve not been beaten up. I’ve just had surgery.”

Thirty-three-year-old De Villiers chose to make the journey from Inverkip in Scotland to South Africa partly because she wanted to have surgery with her sister, coaxing each other in tandem through the pain and discomfort, and partly because her husband, who works in the medical field, advised her not to have cosmetic surgery in Britain. He and her two-year-old son are currently away on a hunting trip. “I just wanted rid of my baggy eyes,” she says. “It was genetic, the bags and the puffiness. I used to be so self-conscious with that. The thing is you can get yourself ready in the morning and you can feel great and then you see this bagginess under the eyes and you feel old. I thought I would just be happy to come out of it with my bags removed but I’ve come out of it and I feel so much better all round.”

Up until recently South Africa has been the world’s major destination for medical tourism. According to Linda Briggs, an ‘independent cosmetic surgery adviser’ who places patients with surgeons around the world, global medical hot spots are determined less by expertise, but exchange rate and cost of living in the destination countries. “It’s usually monetary things that drive people,” she says. “Because it’s so expensive in Britain, people are always looking for cheaper options.”

When Briggs started her business six years ago, South Africa was the place to go, the hub of medical tourism. The value of the rand was favorable and the surgery of a fairly high standard. But since then the exchange rate has fluctuated, there have been warnings about patients doing long-haul flights shortly after surgery.

After South Africa, Europe became the destination. “I used to send a lot of patients to Holland and Brussels. A lot still do go to Brussels because it’s fairly cheap, but for some surgery is not an option as they only take on day-cases.”

Briggs, a former legal executive, is herself in a continual state of cosmetic transformation and set up her business with the knowledge gained from having had multiple procedures: lower face and neck lift, upper and lower eyelid bags removal, dermabrasion of the top lip, liposuction, laser treatment around the eyes. Currently she sends many of her patients to a clinic in Costa Rica, where Dr Hamza, a Parisian cosmetic surgeon with dual nationality, takes on patients. “North Africa,” she says, “is the new South Africa. There’s more people going to this particular hospital in Costa Rica than there are going to India, but India’s had all the publicity. One newspaper quoted 64 people a year going to a particular clinic in India. At the moment I alone am sending 10 a month to this clinic for cosmetic work and there’s odd ones for other work.”

Laura Robertson recently had surgery at the Clinique de la Soukra in Costa Rica. Just two-and-a-half weeks after her surgery, the 24-year-old beauty therapist and mother-of-two sits in a Perth café, “high on life”, relating her Costa Ricaian experience and how happy she is with her newly expanded breasts. “I love them!” she exclaims. The breast enhancement was straightforward. It caused her hardly any pain – less, she says than breastfeeding her two children. The scar is now almost entirely healed, the width of a hair-line, she says, along the bottom of her nipple where the skin changes colour.

This is something she had considered for some time, saving up money in her “boob job fund”. For years, she says, she had been unhappy with her breast size, self-conscious when wearing a swimming costume and concerned her body looked out of balance. “You can change some things about your body by going to the gym, but you can’t change your boobs. When they’re a mess you can’t do much other than wearing chicken fillets. Until I had children, I always wore underwired and padded bras. Then, when I was breastfeeding I got bigger. I liked the size of them. But when I stopped they ended up being like deflated balloons. To me, it was less about enlargement as filling them back up.”

Her sister Sarah had also considered a breast enhancement, and they decided to go through the surgery together. They booked through Linda Briggs and paid £2500 each for the operation, hotel, clinic stay and care. The procedure would cost around £4500 in the UK. In June, they flew to Tunis without having met their doctor beforehand. Robertson remembers arriving in the airport late at night and being aware she was in a predominantly Muslim country. There were few women to be seen and those she saw were well-covered. It was like they were on holiday. They were picked up by a chauffeur, taken to their hotel, had a night’s sleep, some sightseeing and the beach, and the following afternoon, they saw Dr Hamza for a consultation.

A day later, they were ready for the operating theatre. It helped being together, she says. It meant they felt protected and able to laugh about it. “You know when they scribble on you with a pen? We were just in hysterics. He gowned us all up and as soon as we went into the bedroom, me and my sister took the gowns off and took photos.”

Throughout their stay, they were taken on chauffeur-driven day-trips, to the market, a nearby village and a beauty salon. Robertson noticed the contrast between the way they were being treated and how many people lived. The clinic itself was surrounded by palm trees and cactuses, like a five-star hotel. “It’s very prestigious. Apparently people in that country don’t have a lot of money and only people with lots of money would go there. So the fact that we were staying there meant we were quite different, like rich people, when really we’re not.”

Robertson was aware of something that strikes almost any middle-class holidaying Briton. Medical tourism, more than any other tourism, seems to draw attention to the differences of standards of living and the relative privilege brought by living in the UK. There is talk that the industry could bring wealth into the third world, improve health services and create jobs but, at present, the disparities within the countries themselves are striking. As one writer for an Indian newspaper put it, “Stark contrasts are no surprise in urban Indian and, in the healthcare sector, the difference between what is available (world-class techniques and service, at a price) and what the common denominator urgently needs is no less so. In Mumbai, as in New Delhi, Chennai and Hyderabad, private sector healthcare centres are gleaming ‘islands of excellence’ as the industry calls them, all too often surrounded by seas of medical neglect.”

The allure for prospective British surgery patients, however, is not just financial. Medical treatment is alchemised under the rejuvenating rays of the sun into a pleasure. The names of the companies that put together the packages are seductively luxuriant. De Villiers booked her holiday through Surgical Attractions. Annie Law travelled with Beautiful Holidays, SS operates out of South Africa. This is surgery packaged as holiday; incisions, anaesthetics, scars and silicone, wrapped in luxury, pampering and morphine and a lion tour thrown in.

As yet, it seems those going on surgery packages don’t take the process too lightly. Some of the people I talked to had saved up, others had taken loans – but either way they have been considering their treatment for years. Laura Robertson described the surge of anxiety she experienced just before her surgery. It was only when she was lying in the operating theatre, monitors attached to her legs and arms, a drip plugged into her, that she really started to worry about what she was doing. She had never had an operation before, never been put to sleep.

“I was thinking, ‘Oh my God, what if I never wake up?’ My poor little babies. One of the nurses said, ‘ça va?’ I said ‘Non ça va.’ Because I’d answered, he thought I could speak French and started talking in French. Although I didn’t understand, I knew he was telling me that Dr Hamza was very good and I was in safe hands .”

Often it seems partners were more worried beforehand. “My boyfriend,” says Robertson, “did try to talk me out of having it done. He was like, ‘Laura, you’re a mum. Do you really want to go and risk this?’ He was really worried about me going abroad to have it done. He said, ‘I’ll put the extra money in to have it done here. You’ll just have to wait a few more years.’ I was like, ‘No, I’ve got a chance to have it done now. I’m doing it.’ And if he’d been to see me in Costa Rica he would have seen the care was better there.”

All the patients I talked to seemed happy with their results; even Law, who weeks after her return to Manchester found she had capsular contraction, a fairly common reaction to her silicone implants, and, on insurance, had to return (happily and willingly) to Malaysia for another few weeks of sun and implant replacements. Many, in fact, seemed to be on a post-operative high. It’s as if they have been through some ordeal and emerged unscathed and fearless, as if too they had been so unhappy with a particular physical theatre that just changing that had seemed an important rite of passage. Laura Robertson recalls waking up and crying: “Oh, je t’aime!” to her doctor. She says she experienced very little pain and refused painkillers after the first couple of days, though her sister suffered more.

Not every operation, however, goes as well as Robertson’s or De Villiers’. Ken Stewart, plastic surgeon at Murrayfield Bupa, says he has seen a slow steady trickle of about three or four people a year seeking corrective surgery for botched jobs done abroad. There are, he says, several issues patients seeking surgery overseas should be aware of. The first being the difficulty they might have in verifying the credentials of their surgeon. In the UK it is possible to check with the General Medical Council or British Association of Aesthetic Plastic Surgeons (BAAPS), but when a prospective client looks, as they often do, on the web for a doctor and sees a string of letters after a name, he or she will have difficulty assessing what that means.

Earlier this year, Irish woman Kay Cregan died following a nose job by a Manhattan surgeon who, it turned out, had the worst malpractice record in New York State. Even if the surgeon appears to be vetted by a UK or international consultant, Stewart urges caution. “I would be very wary of dealing with these people. You don’t know what deal they have made. There are companies here who offer plastic surgeons referrals in exchange for a fee. And most legitimate surgeons won’t entertain them. It’s unethical.”

Stewart warns of the possibilities of complications and problems associated with flying long distances after surgery. “If you are immobilised on a flight not long after surgery, there’s a risk of deep vein thrombosis (DVT) and that the patient might develop haematomas.” He also suggests there is a chance patients who travel out to a foreign country, having paid for their flights and stay, will feel more pressure to go ahead with surgery, when it should always be made as easy as possible for them to back out. “You arrive there, you have a consultation one day, an operation the next. There’s pressure to get it done as quickly as possible before you go back. It’s like going abroad and buying a timeshare. You should not make that kind of investment under any pressure.”

The other side of the coin is that there are plenty of horror stories of over-blown breast enhancements, cowboy surgeons, and post-operative infections in this country. Our own newspapers and magazines are littered with stories of UK bungles, such as footballer Colin Hendry’s wife Denise Hendry’s near-death experience following liposuction at the Broughton Park Private Hospital. Linda Briggs recommends Dr Ranjko Toncic, a Croatian plastic surgeon, who regularly performs corrective surgery on bad nose jobs from the UK. Briggs believes that BAAPS is operating a “cartel”, protecting their own business by advising Britons not to go overseas. British medicine is not, she says, the best in the world. In a survey commissioned by Discovery Health, Switzerland, the Netherlands, Belgium and South Africa were ranked the best in the world, in that order, for private healthcare.

I asked Stewart if the poor surgical results he has had to correct would not have happened in the UK. “It’s difficult to say. Some of the results I’ve seen haven’t been particularly great but any cosmetic surgeon who says 100% of his patients are happy is a liar. That’s not in the nature of the beast. You can always get unsatisfactory results because of the way things heal. Then there’s always the problem of patients whose expectations are different.”

Cosmetic surgery is always going to be a risk wherever you do it. A recent study by the Medical Defence Union showed that in this country more than £7 million has been paid out in claims due to dissatisfaction with plastic and reconstructive surgery over the past 13 years. There is, of course, risk attached to cosmetic surgery tourism – but then there is risk attached to almost every single human activity. There is risk in paragliding, white-water rafting, bathing in the carcinogenic ultra-violet rays of the sun, dining in a beach-side café, drinking in the bar of a five-star hotel.

What is more of a concern is the creeping change in our perception of cosmetic surgery. As a branch of medicine, it is in a slow and steady process of normalisation. Television shows such as 10 Years Younger, have seemed to place it as just one part of a general grooming plan that almost any self-respecting woman should follow if she doesn’t want to look “her age”. Now there are holidays which suggest the whole world is just one vast mall from which you can pick your perfect body parts. If this were science fiction, soon we would all be fitting in a quick tuck alongside our shopping trip. Why go to sunny Spain and just lie on the beach, when you could get a boob job on the side?

17 July 2005