**5. Legal aspects**

We live in a society of litigation where the doctors are easy prey to the ambition of the lawyers and some patients, a society where the governments create groups that exaggerate the rights of the patients making them believe that the improper results of the medical procedures are by negligence. There is a social environment—especially in government hospitals—where physicians are forced to work with multiple deficiencies as a routine practice, where health workers do not have adequate equipment and supplies, with long hours of work and few or no rights at all. There are few and inadequate preventive or curative programs [91]. The syndrome of professional exhaustion (burnout syndrome) has not been considered as a professional disease. To err is human and in this inadequate situation, it becomes a potential threat.

Anesthesiology is a science, with a high risk of undesirable events secondary to the use of drugs and techniques with narrow safety margins that facilitate unexpected complications. On the other hand, plastic surgery is a specialty where the unrealistic high expectations of many patients mean that despite adequate results—surgeons and anesthesiologists can trigger demands—when these results are not what the patient expects, and even when there are no complications. A growing number of patients establish negligence or malpractice claims justified or not—and our practice tends toward an environment with a high incidence of litigation that sometimes forces specialists to search for geographic areas with a lower incidence of lawsuits [92]. Frequently, decisions of the legal system do not depend on the opinions of medical experts, or medical experts are not properly trained to review the events of a lawsuit in all specialties of medicine and surgery. Patients, their families, and lawyers usually make demands that do not progress due to lack of elements that support malpractice. An attorney should not file a lawsuit without the opinion of a physician skilled in the subject [93].

secondary to injection of unknown filler, and **Figure 6** is an MRI that shows fillers injected in the buttocks, which produce fibrosis and deformations of the region by erratic migration,

**Figure 6.** Deformities in the buttocks secondary to unknown substances. Observe extreme fibrosis.

Undoubtedly, the meticulous selection of each patient is the key to success in plastic surgery. When a patient does not have a physical and mental state required to undergo plastic surgery, the procedure should be deferred or canceled regardless of the interests of the patient and/or the medical group. When the complexity and risk of the procedure exceed the capacity of the surgical unit and/or the medical group, it is appropriate to refer the patient to a surgical unit or hospital with adequate resources [9, 86–89]. No anesthesia procedure should be considered as a minor method, and it is always necessary to work in a safe and effective surgical facility, following established guidelines, and in permanent communication with

A study conducted in Havana Cuba [90] with 26 patients from that country found that personality traits can determine poor choice of people who apply for cosmetic surgery, some with psychosis and dysmorphophobia that induce expectations higher than the real ones.

We live in a society of litigation where the doctors are easy prey to the ambition of the lawyers and some patients, a society where the governments create groups that exaggerate the rights of the patients making them believe that the improper results of the medical procedures are by negligence. There is a social environment—especially in government hospitals—where physicians are forced to work with multiple deficiencies as a routine practice, where health workers do not have adequate equipment and supplies, with long hours of work and few or no rights at all. There are few and inadequate preventive or curative programs [91]. The syndrome of professional exhaustion (burnout syndrome) has not been considered as a professional disease. To err is human and in this inadequate situation, it becomes a potential threat.

which are very difficult or impossible to correct.

144 Anesthesia Topics for Plastic and Reconstructive Surgery

surgeons and nurses.

**5. Legal aspects**

**4. Recommendations to reduce complications**

Park et al.'s [94] study of negligence claims in plastic surgery found responsibility between 30 and 100% of the cases, although the courts recognized that the economic compensation should be adjusted according to the victim, especially when there are associated pathologies which limit and make fairer compensation. Paik et al. [5] reviewed 292 cases of verdicts and liquidation reports in cosmetic breast surgery; the most common lesion was breast disfigurement in 53.1%, and negligent misrepresentation was 98% more likely to be resolved in favor of the complainant, while fraud was 92% more amenable to the complainant. The most common causes of citation were negligence in 88.7% and lack of informed consent in 43.8%. About 58.3% of the cases were in favor of the defendant and 41.7% in favor of the plaintiff. The compensation percentage agreed was 33.4 and 8.3% settlement. Payments ranged from \$ 245,000 to \$ 300,000 USD. A study with 88 cases of demand found in the west legal database [95] examined facial surgery procedures and found that 62.5% were decided in favor of the surgeon, 9.1% made agreements out of court, and 28.4% went to court for damages due to medical malpractice. The average payment was \$ 577,437 USD, and the jury average was \$ 352,341 USD, with blepharoplasty and rhytidectomy being the most litigated. In 38.6% of these cases, there were faults in the informed consent. There were also quarrels and disfigurements, functional considerations, and postoperative pain. The authors emphasize the importance of communication between patients and physicians regarding expectations as well as document benefits, alternatives, and specific risks. These studies show that negligence favors the demands in this clinical environment and emphasize that adequate transparency and communication are the key in the doctor-patient relationship, as mentioned in a previous publication [6].

Lawyers have promoted the lawsuit as a part of their modus vivendi. "Have you suffered as a result of a cosmetic procedure that you believe is due to the negligence of the surgeon? If you believe that your surgeon acted negligently and outside of his/her duty to care for you as a patient, we can help you." This type of information is found on the Internet, and it is associated to websites that guide patients on how to formulate their demands. In Colombia, doctors have expressed their concerns about the rigidity of their penal system [96], which temporarily suspended a plastic surgeon, in addition to imposing a prison for less than a year and compensation to the patient for 150,000,000 Colombian pesos (approximately 52,290 USD) in a complicated liposuction with necrotizing fasciitis. The authors discuss different legal, ethical, and surgical, among other topics, and at the end, they argue the possibility to stop practicing surgery due to legal imputations every time a complication occurs. Although this would be an extreme measure, there are many colleagues who have retired after an incident. Well-qualified and experienced anesthesiologists and surgeons are not exempt from perioperative complications.

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