IN RE: STATE OF FLORIDA BOARD OF NURSING Final Order No. DOH-21-1525-J)s -MQA FILED DATE- NOV O 3 2021 ~•rlm ,., of Heolth ··~~l~ THE PETITION FOR DECLARATORY STATEMENT OF: ALLYSONSAUBER,APRN FINAL ORDER THIS MATTER came before the Florida Board of Nursing (Board) pursuant to Section 120.565, Florida Statutes. At a duly-noticed public meeting held on October 7, 2021, in Kissimmee, Florida, the Board considered a Petition for Declaratory Statement filed by Allyson Sauber (Petitioner). The Petition was filed with the Depat1ment of Health Clerk on August 19, 2021; a copy of which is attached hereto. The Petition was duly filed and noticed in the Florida Administrative Register in Volume 47, Number 165, on August 25, 2021. On September 13, 2021, a Motion to Intervene was filed on behalf of the Florida Medical Association, Inc, Florida Society of Plastic Surgeons, Inc., Florida Society of Dermatology and Dermatologic Surgery, Inc., and Florida Osteopathic Medical Association in opposition to the filed Petition for Declaratory Statement. Petitioner was not present at the hearing. The Board was represented by Deborah Bartholow Loucks, Senior Assistant Attorney General. Christopher Nuland, Attorney at Law, appeared on behalf of the intervenors. The Board granted the Petition to Intervene and heard comments and discussion from the intervenors. The Board denied the Petition because it did not have sufficient information upon which to formulate a proper response. The intervenors dismi.ssed their Motion. THEREFORE, the Petition for Declaratory Statement is hereby denied. I
Transcript
IN RE:
STATE OF FLORIDA BOARD OF NURSING
Final Order No. DOH-21-1525-J)s -MQA
FILED DATE- NOV O 3 2021 ~•rlm ,., of Heolth
··~~l~ THE PETITION FOR DECLARATORY STATEMENT OF: ALLYSONSAUBER,APRN
FINAL ORDER
THIS MATTER came before the Florida Board of Nursing (Board) pursuant to Section
120.565, Florida Statutes. At a duly-noticed public meeting held on October 7, 2021, in
Kissimmee, Florida, the Board considered a Petition for Declaratory Statement filed by Allyson
Sauber (Petitioner). The Petition was filed with the Depat1ment of Health Clerk on August 19,
2021; a copy of which is attached hereto. The Petition was duly filed and noticed in the Florida
Administrative Register in Volume 47, Number 165, on August 25, 2021. On September 13,
2021, a Motion to Intervene was filed on behalf of the Florida Medical Association, Inc, Florida
Society of Plastic Surgeons, Inc., Florida Society of Dermatology and Dermatologic Surgery,
Inc., and Florida Osteopathic Medical Association in opposition to the filed Petition for
Declaratory Statement.
Petitioner was not present at the hearing. The Board was represented by Deborah
Bartholow Loucks, Senior Assistant Attorney General. Christopher Nuland, Attorney at Law,
appeared on behalf of the intervenors.
The Board granted the Petition to Intervene and heard comments and discussion from the
intervenors.
The Board denied the Petition because it did not have sufficient information upon which
to formulate a proper response. The intervenors dismi.ssed their Motion.
THEREFORE, the Petition for Declaratory Statement is hereby denied. I
This Order shall become effective upon filing with the Clerk of the Department of
Health.
DONE AND ORDERED this ~!!.d day of November, 2021.
BOARD OF NURSING
~ It tXCI iu,nJ w, Joe R. Baker, Jr., Executive Director for Deborah McKeen, CD-LPN, BS, Chair
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a true and correct copy of the foregoing has been provided by
U.S. Mail to: Allyson Sauber, 9385 165th Place North, Jupiter, Florida 33478 and by
electronic mail to: counsel of record for the intervenors, Christopher Noland,
The following manager is delegated authority for the Board office as noted:
I 0/28-29 Nicole Benson Program Ops Administrator
Thank you.
JBjr/ms
From: Sent: To:
Subject:
Baker, Joe Tuesday, November 2, 2021 5:47 AM Angela Southwell; Carney, KC; Debbie McKeen; DL MQA Board of Nursing/CNA; Hartman, Janet E; Knispel, Matthew L; Pouncey, Lola T; Wenhold, Jennifer; Gabadage, Gangul; Johnson, Helaine; Johnson, Jeffrey C; Landry, Gary P; Love, Andrew; Parsons, Victoria R; Witters, Matthew G; Perez, Chelsea K; David Flynn; Deborah Loucks; Hollingsworth, Jessica
Re: Delegation Memo -- 10/28-29
This delegation is extended to include today, 11/2. Thank you.
Sent from my FDOH iPhone
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To the Florida Department of Health.
Request for a "Petition for a Declaratory Statement"
FILED DEPARTMENT OF HEALTH
DEPUTY CLERK CLERK: j1. mamfa :M.oraCes DATE: AUG l 9 2021
"Petition for Declaratory Statement Before the Florida Health Department and Florida Board of Nursing"
Petitioner: Allyson Sauber APRN in Florida APRN9430583 9385 i 65th Pl. N., Jupiter, FL 33478 (4 i 9) 464-2033 [email protected] (no fax number)
No legal representative
Seeking clarification on whether
i. I, as a Family Nurse Practitioner in the state of Florida, am able to legally perform laser liposuction with subsequent autologous fat transfer procedure (with Beautifill machine, by Alma)?
a. With my only training being that provided by the Alma company (9 hours of observation of the procedure, followed by 6-8 hours of performing the procedure under the supervision of a physician)?
b. If further training is required, what would this include - would this require me to obtain an RNFA, perform a certain number of cases under direct physician supervision?
c. Am I able to perform this procedure in outpatient office setting (level i office procedure, with less than i 000cc fat removal) - without a physician directly present (and only available by phone)? (under a collaborating agreement with a plastic surgeon)
There is no documentation to state that APRNs in Florida can or cannot perform laser liposuction with autologous fat transfers. This procedure harvests the fat in a low intensity liposuction procedure (using only oral medications like Tramadol and Xanax, with tumescent localized anesthesia used). There is not general anesthesia and the patient is awake and oriented, able to physically move into different positions to assist the practitioner during the procedure.
This legal gray zone - where it is not clearly documented in either the Board of Nursing or the Health Department - is of concern to myself.
I am working at a medical spa that seeks to have this machine used by myself, an APRN. The collaborating plastic surgeon is not trained in this particular machine and will not be on site for these procedures, though available by phone contact. The procedure would require a crash cart and does involve some blood loss, though reported to be minimal enough to not require replacement IV fluids given.
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My current credentials include: my FNP licensure, with my only surgical experience working in an ENT clinic performing nasal endoscopies and ear procedures, and a class by Alma, the manufacturers of the Beautifill machine (includes 9 hours of observation of procedures, 9 hours of hands-on procedure time with supervising physician).
As liposuction is a procedure with significant potential risks to the patient, I want to confirm that this procedure could be considered within my scope of practice.
I have seen other APRNs advertising this procedure, performed by themselves in offices with and without doctors present. However, I have also talked to a lot of plastic surgeons dealing with the fall out of inexperienced practitioners trying to perform such a procedure, resulting in patient injury.
I am interested in providing my patients with the best, safest care. I am interested in gaining clarifications on the questions above - as the medical spa world in Florida is booming and as machines come out that offer non-surgeons ways to provide laser fat transfers. We need clarification in this industry.
According to Florida Board of Nursing website,
"Nurses have the option of filing a "Petition for Declaratory Statement". In many instances nursing duties and responsibilities are not specifically addressed in the Florida Nurse Practice Act (Chapter 464, FS), or the Rules of the Florida Board of Nursing (Title 64B9, Florida Administrative Codes).
I have looked within the Nurse Practice Act and the Rules of the Florida Board of Nursing - I am unable to find definitive statements that indicate that laser liposuction is within or outside of an APRN's scope of practice.
This statement from the board discusses thatAPRNs can perform functions as indicated in a collaborative agreement with a physician:
Statutory authority on protocols is Section 464.012(3), F.S. -An advanced practice registered nurse shall perform those functions authorized in this section within the framework of an established protocol which must be maintained onsite at the location or locations at which an advanced practice registered nurse practices.
This statement is unclear whether a protocol agreement between a physician and APRN is all that is needed to establish whether an APRN can perform a laser liposuction procedure.
The following documentation is from 464.0123, "Autonomous practice by an advanced practice registered nurse:"
(3) Practice Requirements, 5., (c) An advanced practice registered nurse engaging in autonomous practice under this section may not perform any surgical procedure other than a subcutaneous procedure.
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While I am cunently NOT autonomous, this is the only indication that I can find in legal documentation that states what APRNs may NOT do, as far as surgical procedures. Does the same guidelines apply to APRNs working alone in the office, under a collaborative agreement with a physician?
This following statement is of concern - by perforn1ing a liposuction procedure, am I purporting to have skills that are outside of my specialty as a Family Nurse Practitioner? Is the ability to perfmm liposuction only something that a physician or physician -assistant can perform?
(s) For an advanced practice registered nurse registered under s. 464.0123: 11. Advertising or holding himself or herself out as having certification in a specialty that he or she has not received.
With gratitude for your consideration,
Allyson Sauber APRN (FNP-C), MSN, RN
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September 13, 2021
Florida Board of Nursing Attention: Executive Director 4052 Bald Cypress Way, Bin C-02 Tallahassee, FL 32399-3258 [email protected]
FILED DEPARTMENT OF HEAL TH
DEPUTY CLERK
CLERK: Bv4>lBe4-- Coo.-,fe,y DATE: 9/13/2021
FLORIDA MEDICAL ASSOCIATION, INC., FLORIDA SOCIETY OF PLASTIC SURGEONS, INC., FLORIDA SOCIETY OF DERMATOLOGY AND
DERMATOLOGIC SURGERY, INC., AND FLORIDA OSTEOPATHIC MEDICAL ASSOCIATION, INC. MOTION TO INTERVENE IN FLORIDA
BOARD OF NURSING'S CONSIDERATION OF THE PETITION FOR DECLARATORY ST A TEMENT IN OPPOSITION OF PETITIONER ALLYSON
SAUBER, A.P.R.N.
The Florida Society of Plastic Surgeons, Inc. ("FSPS"), the Florida Society of
Dermatology and Dem1atologic Surgery, Inc. ("FSDDS"), the Florida Medical
Association, Inc. ("FMA"), and the Florida Osteopathic Medical Association, Inc.
("FOMA"), each by and through its undersigned counsel, hereby respectfully petition the
Florida Board of Nursing to allow each of the Petitioners to intervene in the Board of
Nursing's discussion of the above Petition in opposition to the Petitioner, pursuant to
Rule 28.106.205, Florida Administrative Code. In support of the proposed Intervenors'
motion, each of the proposed Intervenors hereby states:
1. The Florida Medical Association, Inc. is a Florida-based trade organization
comprised of over 25,000 Florida physicians, many of whom specialize in
dermatology, plastic surgery, or aesthetic medicine, part of which
practice includes the performance of liposuction with subsequent fat
transfer procedures which are the subject of this Petition. As a result,
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members of the FMA, as physicians, would be adversely affected if
providers not licensed either pursuant to Chapter 458 or 459 of the
Florida Statutes were allowed to practice specialized medicine without
the proper education, training, or physician supervision. Further, several
members of the FMA own, operate, and practice in medical spa settings
and supervise advanced practice registered nurses. The FMA routinely
participates in advocacy efforts on behalf of its members in matters
concerning the rights and obligations of physicians, including their
supervision responsibilities.
2. FMA's address, phone number and facsimile number are as follows:
Therefore, a substantial number of the members of each of the proposed
Intervenors would be substantially affected by the Board's decision in
this matter, as they have a unique and vested interest in the outcome of
the subject Petition. As a result, the substantial interests of each of the
proposed Intervenors will be affected by the proceeding, and each of the
proposed Intervenors therefore has standing to participate in these
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proceedings. See Florida Home Builders Association v. Department of
Labor and Employment Security, 412 So.2d 351 (Fla. 1982).
16. The Petitioner is licensed as an "Advanced Practice Registered Nurse,"
pursuant to Florida Statute Section 464.012. Section 464.012, F.S., sets
forth the scope of practice of such practitioners, to wit:
17. 464.012 Licensure of advanced practice registered nurses; fees; controlled substance prescribing.-
(1) Any nurse desiring to be licensed as an advanced practice registered nurse must apply to the department and submit proof that he or she holds a current license to practice professional nursing or holds an active multistate license to practice professional nursing pursuant to s. 464.009 5 and that he or she meets one or more of the following requirements as determined by the board:
(a) Certification by an appropriate specialty board. Such certification is required for initial state licensure and any licensure renewal as a certified nurse midwife, certified nurse practitioner, certified registered nurse anesthetist, clinical nurse specialist, or psychiatric nurse. The board may by rule provide for provisional state licensure of certified registered nurse anesthetists, clinical nurse specialists, certified nurse practitioners, psychiatric nurses, and certified nurse midwives for a period of time determined to be appropriate for preparing for and passing the national certification examination.
(b) Graduation from a program leading to a master's degree in a nursing clinical specialty area with preparation in specialized practitioner skills. For applicants graduating on or after October 1, 1998, graduation from a master's degree program is required for initial licensure as a certified nurse practitioner under paragraph (4)(a).
1. For applicants graduating on or after October 1, 2001, graduation from a master's degree program is required for initial licensure as a certified registered nurse anesthetist who may perform the acts listed in paragraph (4)(b).
2. For applicants graduating on or after October 1, 1998, graduation from a master's degree program is required for initial licensure as a certified nurse midwife who may perform the acts listed in paragraph ( 4)(c).
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3. For applicants graduating on or after July 1, 2007, graduation from a master's degree program is required for initial licensure as a clinical nurse specialist who may perform the acts listed in paragraph ( 4)(d).
(2) The board shall provide by rule the appropriate requirements for advanced practice registered nurses for the advanced nursing practices of certified nurse midwives, certified nurse practitioners, certified registered nurse anesthetists, clinical nurse specialists, and psychiatric nurses.
(3) An advanced practice registered nurse shall perform those functions authorized in this section within the framework of an established protocol that must be maintained on site at the location or locations at which an advanced practice registered nurse practices, unless the advanced practice registered nurse is registered and practicing under s. 464.0123. In the case of multiple supervising physicians in the same group, an advanced practice registered nurse must enter into a supervisory protocol with at least one physician within the physician group practice. A practitioner currently licensed under chapter 458, chapter 459, or chapter 466 shall maintain supervision for directing the specific course of medical treatment. Within the established framework, an advanced practice registered nurse may: (a) Prescribe, dispense, administer, or order any drug; however, an advanced practice registered nurse may prescribe or dispense a controlled substance as defined ins. 893.03 only if the advanced practice registered nurse has graduated from a program leading to a master's or doctoral degree in a clinical nursing specialty area with training in specialized practitioner skills.
(b) Initiate appropriate therapies for certain conditions.
(c) Perform additional functions as may be determined by rule in accordance withs. 464.003(2).
(d) Order diagnostic tests and physical and occupational therapy.
(e) Order any medication for administration to a patient in a facility licensed under chapter 395 or part II of chapter 400, notwithstanding any provisions in chapter 465 or chapter 893.
( 4) In addition to the general functions specified in subsection (3), an advanced practice registered nurse may perform the following acts within his or her specialty:
(a) The certified nurse practitioner may perform any or all of the following acts within the framework of established protocol:
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1. Manage selected medical problems. 2. Order physical and occupational therapy. 3. Initiate, monitor, or alter therapies for certain uncomplicated acute illnesses. 4. Monitor and manage patients with stable chronic diseases. 5. Establish behavioral problems and diagnosis and make treatment recommendations.
(b) The certified registered nurse anesthetist may, to the extent authorized by established protocol approved by the medical staff of the facility in which the anesthetic service is performed, perform any or all of the following:
1. Determine the health status of the patient as it relates to the risk factors and to the anesthetic management of the patient through the performance of the general functions. 2. Based on history, physical assessment, and supplemental laboratory results, determine, with the consent of the responsible physician, the appropriate type of anesthesia within the framework of the protocol. 3. Order under the protocol preanesthetic medication. 4. Perform under the protocol procedures commonly used to render the patient insensible to pain during the performance of surgical, obstetrical, therapeutic, or diagnostic clinical procedures. These procedures include ordering and administering regional, spinal, and general anesthesia; inhalation agents and techniques; intravenous agents and techniques; and techniques of hypnosis. 5. Order or perform monitoring procedures indicated as pertinent to the anesthetic health care management of the patient. 6. Support life functions during anesthesia health care, including induction and intubation procedures, the use ofappropriate mechanical supportive devices, and the management of fluid, electrolyte, and blood component balances. 7. Recognize and take appropriate corrective action for abnormal patient responses to anesthesia, adjunctive medication, or other forms of therapy. 8. Recognize and treat a cardiac arrhythmia while the patient is under anesthetic care. 9. Participate in management of the patient while in the postanesthesia recovery area, including ordering the administration of fluids and drugs. 10. Place special peripheral and central venous and arterial lines for blood sampling and monitoring as appropriate.
(c) The certified nurse midwife may, to the extent authorized by an established protocol which has been approved by the medical staff of the health care facility in which the midwifery services are performed, or
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approved by the nurse midwife's physician backup when the delivery is performed in a patient's home, perform any or all of the following: 1. Perform superficial minor surgical procedures. ( emphasis added) 2. Manage the patient during labor and delivery to include amniotomy, episiotomy, and repair. 3. Order, initiate, and perform appropriate anesthetic procedures. 4. Perform postpartum examination. 5. Order appropriate medications. 6. Provide family-planning services and well-woman care. 7. Manage the medical care of the normal obstetrical patient and the initial care of a newborn patient.
(d) The clinical nurse specialist may perform any or all of the following acts within the framework of established protocol:
1. Assess the health status of individuals and families using methods appropriate to the population and area of practice. 2. Diagnose human responses to actual or potential health problems. 3. Plan for health promotion, disease prevention, and therapeutic intervention in collaboration with the patient or client. 4. Implement therapeutic interventions based on the nurse specialist's area of expertise and within the scope of advanced nursing practice, including, but not limited to, direct nursing care, counseling, teaching, and collaboration with other licensed health care providers. 5. Coordinate health care as necessary and appropriate and evaluate with the patient or client the effectiveness of care. (e) A psychiatric nurse, who meets the requirements ins. 394.455(36), within the framework of an established protocol with a psychiatrist, may prescribe psychotropic controlled substances for the treatment of mental disorders.
18. It should be noted that even specially trained nurse midwives may only
perform "superficial minor surgical procedures."
19. It should also be noted that F.S. 464.0123 states that Autonomous APRNs
may not perform any surgical procedure other than a "subcutaneous
procedure."
20. Laser liposuction, like all liposuction, involves the surgical insertion of
both the laser and a cannula into the subject area and has been associated
with bowel perforations and other major complications. The risk of
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complications is enhanced considerably when the transfer of the
extracted fat to other parts of the body is added to the procedure, as has
repeatedly been seen with regard to such procedures as gluteal fat
transfers.
21. In 2019, the Legislature recognized the dangers of liposuction when it
created Florida Statutes 458.328 and 459.0138, which state in pertinent
part:
458.328 and 459.0138 Office surgeries.
(1) REGISTRATION.-
(a) An office in which a physician [emphasis added] performs a liposuction procedure in which more than 1,000 cubic centimeters of supernatant fat is removed, a Level II office surgery, or a Level III office surgery must register with the department unless the office is licensed as a facility under chapter 390 or chapter 395.
22. The above statutes demonstrate that the Legislature did not even
envision the possibility of non-physicians performing such procedures.
23. Recognizing the need for added safety, the Florida Board of Medicine and
Florida Board of Osteopathic Medicine have enacted strict rules for the
performance of liposuction, especially liposuction in excess of 1,000 cc of
supernatant fat and fat transfer procedures. For instance, 64B8-
9.009(2)(d)-(f) and 64B15-14.007(2)(d)-(f) state:
(d) In any liposuction procedure, the surgeon is responsible for determining the appropriate amount of supernatant fat to be removed from a particular patient. A maximum of 4000cc supernatant fat may be removed by liposuction in the office setting. A maximum of S0mg/kg of Lidocaine can be injected for tumescent liposuction in the office setting. (e) Liposuction may be performed in combination with another separate surgical procedure during a single Level II or Level III operation, only in the following circumstances:
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1. When combined with abdominoplasty, liposuction may not exceed 1000cc of supernatant fat, 2. When liposuction is associated and directly related to another procedure, the liposuction may not exceed 1000 cc of supernatant fat, 3. Major liposuction in excess of 1000cc supernatant fat may not be performed in a remote location from any other procedure.
24. Likewise, 64B8-9.009(3)(b) and 64B15-14.007(3)(b) require several
other precautions, even for Level I procedures, to wit:
(b) Standards for Level I Office Surgery.
1. Training Required. Surgeon's continuing medical education should include: proper dosages; management of toxicity or hypersensitivity to regional anesthetic drugs. One assistant must hold current certification in an American Heart Association, American Safety and Health Institute, American Red Cross, Pacific Medical Training approved Basic Life Support course with didactic and skills components, or ACLS Certification Institute Basic Life Support course with didactic and skills components, and the surgeon must hold current certification in an American Heart Association, American Safety and Health Institute, Pacific Medical Training approved Advanced Cardiac Life Support course with didactic and skills components, or ACLS Certification Institute Advanced Cardiac Life Support course with didactic and skills components.
2. Equipment and Supplies Required. Intravenous access supplies, oxygen, oral airways, and a positive pressure ventilation device shall be available in the office, along with the following medications, stored per manufacturer's recommendation: a. Atropine 3 mg, b. Diphenhydramine 50 mg, c. Epinephrine 1 mg in 10 ml, d. Epinephrine 1 mg in 1 ml vial, 3 vials total; and, e. Hydrocortisone 100 mg. f. If a benzodiazepine is administered, Flumazenil 0.5 mg in 5 ml vial, 2 vials total; and, g. If an opiate is administered, Naloxone 0.4 mg in 1 ml vial, 2 vials total.
3. When performing minor procedures such as excision of skin lesions, moles, warts, cysts, lip om as, and repair oflacerations or surgery limited to the skin and subcutaneous tissue performed under topical or local anesthesia, physicans are exempt from subparagraphs (3)(b)1. and 2., above. Current Basic Life Support certification is recommended but not required.
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4. Assistance of Other Personnel Required. No other assistance is required, unless the specific surgical procedure being performed requires an assistant.
25. By contrast, the Board of Nursing has no such rules in place to protect
patients who may have such procedures performed by any of its
licensees.
26. Based upon the above, the parties to this Motion aver that the intended
conduct of Petitioner is inconsistent with existing Florida law, which does
not authorize a family-practice APRN to perform such procedures, would
be dangerous to the public in that the regulatory protections imposed
upon physicians do not exist for APRNs, and the procedures
contemplated in the Petition should therefore be prohibited.
27. The authority of an agency to issue a declaratory statement is limited by
Section 120.565, F.S., to a determination "as to the applicability of a
statutory provision ... to the petitioner's particular set of circumstances."
Lennar Homes, Inc. v. Department of Business and Professional Regulation,
Division of Florida Land Sales, Condominiums and Mobile Homes, 888 So.
2d SO, 53 (Fla. 1st DCA 2004).
28. In the instant case, the Board is being asked to ascertain whether a
family-practice APRN may, without physician supervision and with only
minimal training, perform laser-assisted liposuction along with
autologous fat transfer. The Board is also asked to determine what level
and type of training would be sufficient for an APRN to perform such
procedures. In essence, the Petitioner is requesting the Board to adopt a
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statuto1y interpretation that would be applicable to each and every
advanced practice registered nurse in Florida to allow them to perform
such procedures, contrary to the clear intention and language of the
statutes and rules governing liposuction.
29. When an agency is called upon to issue a declaratory statement "which
would require a response of such a general and consistent nature as to
meet the definition of a rule, the agency should either decline to issue the
statement or comply with the provisions of Section 120.54 governing
rulemaking." Agency for Health Care Administration v. Wingo. 697 So.2d
1231, 1233 (Fla. 1st DCA 1997). Because the questions presented by the
Petition are overly broad, granting the Petition would constitute an
unlawful non-rule policy and should therefore be dismissed.
WHEREFORE, the FMA, FSPS, FSDDS, and FOMA, each respectfully requests that,
pursuant to Section 120.565, Florida Statutes, it be allowed to intervene in the subject
proceeding in opposition to the Petitioner and that the Board of Nursing either issue a
Declaratory Order in opposition to Petitioner or dismiss the Petition for Declaratory
Statement.
Respectfully submitted on this 13th day of September, 2021.
~ L. ~
Christopher L. Nuland, Esq.
FLORIDA BAR NO: 890332
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LAW OFFICES OF CHRISTOPHER L. NULAND, P.A.
Counsel for Petitioner Florida Society of Plastic Surgeons, Inc., and Florida
Society of Dermatologists and Dermatologic Surgeons, Inc.
