There was a time when all you saw an eye doctor for was a glaucoma test and a prescription to treat your nearsightedness. If you had crow's feet or a sagging jowl, you'd consult a plastic surgeon.

Not anymore. Once the dominion of specialists, cosmetic surgery is now part of many physicians' practices. Today you can get a chemical peel at a dentist's office. Gynecologists are doing laser hair removal, and just about everyone is offering some form of wrinkle reduction.

In Sarasota, the trend is spreading fast, and as physicians of all types add cosmetic services to their practices-and more people clamor to get them-the implications for patients are profound.

According to the American Society of Plastic Surgeons (ASPS), the number of people having cosmetic plastic surgery has tripled since 1992-and that's just the surgery being done by ASPS members. No one knows for sure how many people are having things done by doctors not affiliated with the society.

That's because, as Dr. James Marsh, a board- certified plastic surgeon who has been operating in Sarasota for 25 years, says, "Anyone with an M.D. can legally perform plastic surgery. You can call yourself a cosmetic or plastic surgeon, open an office surgery suite, and do any cosmetic surgery you like without any supervision or training."

Marsh says he doesn't blame physicians for expanding their repertoires. "The decrease in reimbursements from insurance and Medicare has made it almost impossible for surgeons to cover their overhead and make a decent living," he says.

Dr. Eric Berman, a fellowship-trained neuro-ophthalmologist at Eye Consultants of Sarasota, explains: "Last year, Medicare gave all physicians an across-the-board six percent cut. The effect trickles down to insurance carriers who follow what Medicare pays."

As managed care and dwindling Medicare reimbursements gnaw away at revenues, doctors see cosmetic services as a lucrative and hassle-free way to reproduce income. It's no coincidence that three of the top five procedures being performed today, blepharoplasty (eyelid surgery), microdermabrasion and botox injections, are the most popular additions to traditional medical practices.

But opinions vary about who is most qualified to perform them. Dr. John Leikensohn of the Plastic Surgery Center in Sarasota insists, "The bottom line is, surgery should be performed by surgeons."

Adds Marsh: "Without a basic training in general surgery that a real plastic surgeon learns, lack of knowledge in fluid and electrolyte balance can be potentially lethal, especially in liposuction and long surgeries."

Marsh explains that plastic and reconstructive surgeons complete a five-year general surgery residency. After that they spend two years studying plastic surgery; many follow up with six months to one year of additional sub-specialty training. Marsh and Leikensohn maintain that this extensive surgical training better qualifies them to handle plastic surgery.

But even they concede that practitioners in certain specialties are qualified to handle some cosmetic procedures. For example, ophthalmologists have always been able to correct functional lid problems that interfere with vision. Cosmetic eye surgery has been part of their residency training since 1995 or so, and those who want to specialize in ocular plastic surgery undergo additional fellowship training.

"When problems arise [in eye cosmetic surgeries], they're going to be manifest to the eyes themselves," says Dr. John Fezza, an opthalmologist and ocular facial plastic surgeon at Sarasota's Center For Sight. Because all of the potential side effects that are associated with cosmetic eye surgeries are treated by ophthalmologists, plastic surgeons consider it routine for them to handle the initial cosmetic surgery.

Still, while they express no resistance toward specialists like Berman and Fezza who perform cosmetic surgeries confined to their range of expertise, most plastic surgeons steadfastly oppose physicians handling complicated surgeries unless they are board certified to do so.

Fezza is a member of the American Society of Ophthalmic Plastic & Reconstructive Surgery, and because of his additional training, routinely performs full face-lifts. But Marsh doesn't believe ophthalmologists-even ocular facial plastic surgeons-should be doing face-lifts. "We can teach just about anyone to technically operate," he says. "But some people will never have the judgment it takes to be a surgeon." He says it takes years to become exposed to different scenarios, to be able to "see" below the skin to the muscles.

Dr. Robert Finkelstein, a board-certified dermatologist with Advanced Dermatology in Sarasota, agrees that some procedures are best left to plastic surgeons. But not surprisingly, he also believes some are just as safe in the hands of a dermatologist. "The problem with someone who is not trained to deal specifically with skin is that he may not be equipped to handle certain complications. Botox and glycolic chemical peels are not technically difficult, but my greatest fear is if something happens adversely, it puts the patient in a precarious situation."

Finkelstein says glycolic peels can burn the skin if they're left on too long. Some patients have allergic reactions to the chemicals; others may develop bacterial or viral infections. "Someone can do 100 or 200 peels and never have any problems," he says. "Then they come across a complication that they're not trained to deal with, and the patient must be referred to someone else with the proper expertise."

Marsh says that wrinkle-reducing therapy such as collagen injections and lasers can be learned by any physician, but it helps to have years of experience with the skin. "Laser resurfacing has one of the highest malpractice rates due to inexperience of the operator using the laser and inexperience with how skin heals," the plastic surgeon says.

Even a relatively simple procedure like botox injections can raise alarms. According to the ASPS, botox treatments in 2001 were up 61 percent over the previous year. "If you're already a surgeon, training should take no more than an afternoon," says Marsh. "But even simple procedures can be done incorrectly." Marsh says complications can include bruising, drooping lids or eyebrows (if the needle punctures the wrong muscle), even double vision.

Some physicians say it's not worth the risk. "I will not inject botox," says Dr. Robert Kantor, of the Kantor Eye Institute & Laser Center. "There are other people who have far more expertise. The problem is anyone can do something like that, but you have to be very good at handling the complications."

Further complicating the entire debate is where these procedures are being performed. Since 1992, office-based plastic surgery has soared: liposuction by 389 percent, breast augmentation by 413 percent and eyelid surgery by 139 percent. No one knows for sure if office-based surgeries carry more risk than those done in hospitals, because there is no national reporting system that tracks bad outcomes for cosmetic surgeries.

Fortunately, says Finkelstein, "Florida is a little more strict. In other states, technicians can administer a lot of these practices. At least in Florida, you have to be licensed."

In fact, Florida is one of only 10 states that have placed any sort of regulation on office-based procedures. It has had a system in place for reporting "adverse incidents" from office-based surgeries since 2000 (although that reporting is limited to events requiring hospitalization). It's also one of only five that require office-based surgical practices receive accreditation from organizations such as the Joint Commission on Accreditation of Healthcare Organizations.

"Office surgery suite accreditation is extremely important," says Marsh. "Operations performed in anything but an accredited facility can result in infection, over-sedation and the inability to deal with emergency situations."

To ensure safety, the Florida Board of Medicine has, among other things, decreed that physicians must have hospital privileges to perform any procedure that takes place in their office. "That means a credentialed committee has reviewed your qualifications and certified you to do a procedure," says Leikensohn.

Further, anesthesia must be provided (or at least supervised) by a licensed anesthesiologist-although at press time, the board appeared to be leaning toward allowing waivers for nurse anesthetists and physicians who met certain conditions.

The new regulations caused an uproar among those who provide cosmetic services; but Fezza says, "It's in the best interest of the patient's health." He says many hospitals will not admit cosmetic surgery patients with serious complications if their doctor does not have privileges. In those cases, the patient must seek help from another doctor or an emergency room instead.

Working out such details, like what should and shouldn't take place within a doctor's office, is all part of the wrangling in what many doctors agree is an inevitable expansion of services. "The world has changed a lot. Our medical system hasn't necessarily caught up with that," says Dr. Michael Mercandetti, a facial and ophthalmic plastic surgeon with Ophthalmic and Aesthetic Consultants in Sarasota. "In any bigger city, just by sheer volume, no one type of specialty can lay claim to everyone."

At Center For Sight in Sarasota, full face-lifts, botox treatments, hair replacements and laser hair removal thrive alongside traditional ophthalmology. "It's a natural outgrowth of a practice like ours," says chief operating officer Doug Badertscher. He says the trend of having multi-specialties under one roof has been occurring in major metropolitan areas like New York for nearly 10 years. He says the reason you may just be noticing it here is that until recently, medical advertising was taboo and solo practices didn't have the business experience to invest in public relations. But as practices have grown, so has marketing, and it seems to be paying off. "Patients are asking for it," says Berman, who also performs botox, skin cancer removal and brow lifts.

The trend has even reached the dentist's office. At the Studio for Aesthetic & Biological Dentistry in Sarasota, a technician performs microdermabrasion, and a licensed aesthetician offers facials and glycolic peels.

Consolidation of services is also economical for surgeons. One reason Fezza joined Center For Sight was that affiliation with a larger, respected center supplied a ready pool of referrals.

Badertscher believes that eventually, this type of consolidation will lead to providing full-body plastic surgery under one roof. "It's a natural," he says. "People want one-stop shopping in a quality environment. When you take your car to be serviced, they can do everything from repairing the engine to tinting your windows. Having multiple specialties.within one practice will save time and improve patient services and confidence in the physicians."

Mercandetti acknowledges that this is new territory. "As a doctor, you're trained to fix things," he says. "With cosmetic surgery, you have to be cognizant not to offer services just to offer services. You're not in it to be in competition with spas. You have to bear in mind that you're a doctor first."

What concerns everyone are doctors who expand beyond the realm of their specialty, say, if a dermatologist strays from skin lesion removal and dermabrasion to face-lifts. "Ear, nose and throat doctors are more than qualified to do face-lifts," says Leikensohn. "They are not qualified to do breast augmentations."

Cosmetic and ocular surgeons agree the marketplace is rife with physicians (and even non-medical personnel) performing procedures for which they have little or no training. And not only is there no national reporting system for bad cosmetic surgery outcomes, state and federal insurance companies don't collect such statistics, either. Most of the statistics that do exist are being kept by plastic surgery societies like ASPS, and that data reflects outcomes only for its members.

What little data does exist concerns liposuction, which seems to carry the most risk of all plastic surgeries being performed. A survey of 1,200 plastic surgeons revealed 95 deaths during 496,245 lipoplasties from 1994 to 1998. The majority of those 95 deaths occurred in outpatient settings. That number may well be conservative; the survey was comprised only of board-certified plastic surgeons, who are estimated to perform only about half the total number of lipoplasties.

So until there are reliable statistics available to consumers that track the competence of doctors who are not members of bodies like the ASPS, it is incumbent upon patients to determine how safe their procedure is going to be. "You have to be a consumer," says Finkelstein. "You have to ask questions."

BE SAFE, NOT SORRY

In Florida, anyone with a medical license can perform any medical procedure, so don't reply on advertisements to find a plastic surgeon.

"Find out what training they've had," says Berman. "How commonly they perform a procedure. Look at before and after pictures on prior patients. Check with the Florida Board of Medicine to see if any complaints have been filed against the doctor. If I have a patient who doesn't seem to know what's going on and doesn't ask the right questions, I'm hesitant to do surgery on them." Berman says every doctor should explain all procedures, possible complications, and alternative treatments.

Even if you're having something as simple as a botox injection, make sure the provider is board-certified. If he is not, but says he is working under a doctor's supervision, Fezza advises that you make sure the supervising doctor will at least be in the office should complications arise.

Make sure your physician is board-certified by an organization that is approved by the American Board of Medical Specialties. You can research any medical board on their Web site, http://www.abms.org/, or call (847) 491-9091.

Ask if your surgeon has hospital privileges. Not everyone who performs plastic surgery does. If the one you choose does not, and something goes wrong during your procedure, you'll be going to the emergency room.

Get a second opinion. There's more than one way to perform many cosmetic procedures; another surgeon may be able to give you different options for yours.