2017-18 HSC Section 4 Green Book

Research Original Investigation

Analysis of Rhytidectomy Malpractice Litigation Cases

M edical malpractice litigation (MML) is ingrained in modern medical practice. 1 Despite ongoing reforms and the establishment of organizations to monitor health care quality, 2,3 MML continues to have a profound ef- fect on the US health care system, costing more than $55 bil- lion annually 4 and involving 75% to 99%of all physicians over their career. 5 In addition, physician concerns about MML lead to increased burnout rates 6 anddefensivemedicine, 7 the prac- tice of performing services of little to no medical value for the purpose of patient assurance 8,9 or avoidance of high-risk situ- ations. Such practice leads to unnecessary diagnostics, proce- dures, and hospitalizations 1 with associated complications. In today’s litigious environment, the factors affecting ju- dicial outcomes are increasingly important to understand and are the subject of study in several medical fields. 10-15 Find- ings fromsuch studies are particularly relevant in elective sur- gery. Recent investigations demonstrate that most claims in plastic surgery result from a surgeon’s lack of expertise in the procedure, 16 poor cosmesis and excessive scarring, 16,17 and a perceived lack of informed consent 16,17 (ie, informing pa- tients andmanaging their expectations). 18,19 Studies also sug- gest that the quality of medical records and informed con- sent weigh heavily in judicial decisions to determine claims against plastic surgeons. 8,20 Rhytidectomy accounts for a sig- nificant portion of all cosmetic procedures and thus is more likely to be involved in MML. 21,22 By analyzing rhytidectomy claims, surgeons performing this procedure can be better educated on strategies to pre- vent litigation and to develop practices more likely to result in positive judiciary outcomes. The objective of this studywas to perform a focused analysis of the outcomes, monetary ef- fects, and allegations raised in MML proceedings involving rhytidectomy. Methods Jury verdict and settlement reports used in this analysis were obtained from Westlaw Next (Thomson Reuters), a publicly available legal database containing state and federal case laws, public records, and other related information frommore than 40000 databases.WestlawandWestlawNext have been used repeatedly to examine and analyze MML. 6,23-25 We searched the database for the term medical malprac- tice in conjunction with several terms for rhytidectomy, in- cluding rhytidectomy, platysmaplasty, platysmoplasty, chin lift, chinlift, necklift, neck lift, facelift, face lift, lifestyle lift, thread lift, MACS lift, and Quick lift , to account for the various proce- dure names associated with the procedure. From this search, 155 court caseswere reported.We removedduplicate andnon- relevant cases and included 89 cases from 1985 to 2015 in our analysis. For each of the 89 cases, we recorded the proce- dure, alleged cause ofmalpractice, case outcome, awardvalue, and specialty of the defendant. Information about whether the facial plastic surgeon in- volved in the casewas trained in head and neck surgery (or ear, nose, and throat specialty) or inplastic surgerywas unavailable in the database. However, for 62 of the 89 cases, we found the

specialty information on individual practice websites and phy- sicianbiographiesonline.Weconductedstatisticalanalysisusing Fisher exact test for categorical variables to compare the pres- ence of a legal allegation against a physician with the outcome favorability for that physician, and Mann-Whitney tests were usedwhereappropriate.Weanalyzedstateand federal court rec- ords containing jury verdicts and settlements for further detail. Data were collected from November 21, 2015, to Decem- ber 25, 2015. Data analysis took place fromDecember 25, 2015, to January 20, 2016. Because all the information used in the study was obtained from publicly available court records, no confidential or protected health recordswere encountered. As such, this analysis required no approval from an institutional review board. Results A total of 89 cases met our inclusion criteria. Most plaintiffs were female (81 of 88 with known sex [92%]), and patient age ranged from 40 to 76 years (median age, 56 years). Fifty- three cases (60%) were resolved in favor of the defendant, while the remaining 36 cases (40%) were resolved with pay- ment (jury settlement [6%] or plaintiff verdict [35%]) of amean $1.4 million (median payment, $0.5 million). Of the cases re- solved with payment, 5 (14%) were by jury settlement with a meanpayment of $1 362 716, and 31 (86%) were by plaintiff ver- dict with a mean payment of $1 635 000. The surgeon specialties found for 62 cases included plas- tics (42 cases [68%]); ear, nose, and throat (17 [27%]), and ocu- loplastics (2 [3%]). Of these 62 cases, 22 (35%) resulted in a mean payment of $681 643 (median payment, $412 500). The mean payment amount and payment frequency (payments in- clude both settlements and plaintiff outcomes) varied by spe- cialty: for plastic surgeons, 15 payments of 42 cases (36%) with amean of $662 007; for ear, nose, and throat specialists, 4 pay- ments of 17 cases (24%) with amean of $288 974; and for ocu- loplastic surgeons, 2 payments of 2 cases (100%) with a mean of $1 705 075. The most common plaintiff allegations were intraopera- tive negligence (61 [69%]), poor cosmesis or disfigurement (57 Key Points Question What factors influence rhytidectomy malpractice litigation and determine poor defendant outcomes? Findings This analysis of 89 medical malpractice litigation cases involving rhytidectomy found that patient dissatisfaction with cosmetic outcome and inadequate informed consent were the most commonly cited factors in pursuing litigation. Intraoperative negligence and facial nerve injury allegations were more likely to result in poor defendant outcomes. Meaning A comprehensive, preoperative informed consent process characterizing specific risks and outcomes is necessary to limit allegations of malpractice in rhytidectomy; however, direct patient harm is most often associated with judicial liability in rhytidectomy malpractice litigation.

JAMA Facial Plastic Surgery Published online February 9, 2017 (Reprinted)

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