Who Owns the Complications? A Call for Accountability in Cosmetic Medical Tourism

Cosmetic medical tourism (CMT), defined as patients traveling abroad for surgical procedures, has expanded rapidly in recent years.1,2 Motivations include lower costs, shorter wait times, and access to procedures unavailable locally.1–4 International providers attract patients with aggressive marketing and may further incentivize travel through discounted pricing.5,6 Unfortunately, patients often return home with unresolved postoperative needs such as drain or suture removal, or, more concerning, serious complications. Reported complication rates reach as high as 74%, with infection, dehiscence, hematoma, and contour abnormalities being most common.1–3 These realities place US plastic surgeons in a challenging position. Providers face a trilemma: a duty to treat patients in need; the risk of uncompensated care for complications from operations they did not perform; and frustration, whether directed toward the patient who sought cheaper care abroad or toward the surgeon who operated without ensuring continuity of care. A survey of 2000 American Society of Plastic Surgeons members highlighted this burden, with most respondents reporting no compensation for treating CMT-related complications.3 Although existing studies have documented complication rates, few have addressed the central question: who bears responsibility for postoperative management? Despite the prevalence of these cases, no clear guidelines exist to direct surgeons managing patients returning from CMT. Ethical tension, financial strain, and implicit bias all shape clinical decision-making in this space. This ambiguity contributes to confusion, frustration, and inefficiencies in care. Recent data underscore this economic burden: at one tertiary center, half of the patients presenting with complications after aesthetic surgery required hospital admission, yet reimbursement rates were only 21.3% for physicians and 25.16% for hospitals.7 We believe responsibility for postoperative management should rest primarily with the operating surgeon. If surgery is performed abroad, it must be that surgeon’s duty to ensure the patient has access to qualified local care for routine postoperative needs and potential complications. This may involve requiring patients to establish local care preoperatively, with written confirmation, or implementing a formal postoperative care contract among the operating surgeon, patient, and local provider. Professional societies such as the American Society of Plastic Surgeons and International Society of Aesthetic Plastic Surgery should not only advocate for continuity-of-care standards but also provide clear frameworks for implementation, including model consent language, educational modules for surgeons and patients, and requirements that member surgeons demonstrate postoperative plans before performing elective procedures on CMT patients. Belza et al7 advocated for a “closed-loop” model of communication between patients and operating surgeons to establish explicit postoperative care plans before surgery abroad. These societies could partner with accrediting bodies or medical tourism facilitators to incorporate these expectations into certification and referral processes. Although these organizations do not oversee licensure, they can promote adherence by linking membership, certification, and referral eligibility to documented continuity-of-care plans. Although all physicians have an ethical duty to treat urgent complications, regardless of where surgery occurred, the current lack of prearranged follow-up places an undue burden on local providers. Establishing formal expectations for postoperative continuity of care will protect patients, ensure accountability, and reduce systemic strain. Plastic surgery without borders must not mean surgery without follow-up. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.