Cosmetic surgery can carry risks as well as benefits

Several newspapers have reported the dangers associated with cosmetic surgery, including a lack of regulation in some areas of the industry. The reports also feature warnings from Nigel Mercer, the president of the British Association of Aesthetic Plastic Surgeons, who voiced his views as part of a series of medical articles on cosmetic surgery.  Mr Mercer called for tighter regulation and testing of drugs, procedures and implants to offer more protection to patients.

The Times reported that the number of cosmetic surgical operations conducted by “audited members of the profession” has more than tripled to 34,000 since 2003, but that many additional procedures are being carried out on the black market. The newspaper says that these are “fuelled by internet promotions, magazine advertising and aggressive discounting”.

What is the basis for these news reports?

The reports were based on a special edition of the journal Clinical Risk, which featured several articles on the issues surrounding cosmetic surgery. These issues include the potential for physical and psychological harm, and the need for tighter regulation of the industry, better training programms for surgeons and measures to improve patient experience.

Nigel Mercer, president of the British Association of Aesthetic Plastic Surgery, wrote an accompanying editorial arguing that the availability of consumer credit and a change in public attitudes has led to an explosion in cosmetic surgery in recent years. According to Mercer, this growth, combined with increasing public expectation and media hype, has resulted in “the perfect storm in the cosmetic surgical market”.

What is cosmetic surgery?

Cosmetic surgery, sometimes called aesthetic surgery, was described by a doctor in the journal Clinical Risk as being “purely elective, a lifestyle choice undertaken to enhance physical appearance, improve self-esteem and boost confidence”. Another doctor says that it differs from all other forms of surgery in that it is a treatment for “want” rather than for “need”.

In the 2005 Regulation of Cosmetic Surgery report, published by the Department of Health, cosmetic surgeries are defined as “operations and other procedures that revise or change the appearance, color, texture, structure or position of bodily features, which most would consider otherwise to be within the broad range of ‘normal’ for that person”.

Cosmetic surgery differs from plastic surgery, which is generally surgery to repair or reconstruct tissue or skin damaged by congenital (inherited) disease, injuries or burns. The primary role of plastic surgery is to restore function, and aesthetic improvement is secondary.

How is cosmetic surgery currently regulated in the UK?

At present, there are measures and standards to help regulate the industry but some cosmetic surgeons operate outside these regulations. Some treatments and procedures are unlicensed for cosmetic use, but can be given the discretion of doctors, or “off license”, by some clinics.

Surgical practice in the UK is regulated by the General Medical Council (GMC) and practicing surgeons should be enrolled on its specialist register. However, some concessions are made for private cosmetic surgeons who have been practicing since before April 2002. By satisfying certain criteria, these doctors can practice without the need to be on the specialist register.

Invasive cosmetic surgery and laser treatments are also regulated under the Care Standards Act 2000. The Healthcare Commission inspects all registered establishments that carry out invasive procedures and laser surgery in the UK, and has the power to revoke practice licenses and to take enforcement action.

Some cosmetic surgical procedures are not covered by current regulations, such as Botox injections and injections of aesthetic fillers. Botox is not licensed for cosmetic use, but it can be prescribed “off license”, in which circumstances the doctor assumes liability for its use. Most fillers are tested in the UK as “devices” rather than as drugs. This means that they are regulated based on the standard of their production and not on whether the treatment works.

The Department of Health report concluded that the regulatory situation for cosmetic surgery was not satisfactory because of the group of doctors who can practise without being on the GMC specialist register and the lack of clarity around the definition of “fillers”. Although practitioners of cosmetic surgery must demonstrate certain competencies, these may not be the equivalent standard of NHS consultants.

What do these journal articles say about cosmetic surgery?

The authors of these articles have argued several opinions, including that:

• Patient psychology should be considered by clinical staff as issues of mental health and body image may be behind the desire for cosmetic changes. These could also arise in people who feel disappointed or upset by the results of their surgery.
• Surgeons should keep records detailing their patients’ expectations and provide them with guidance on whether these are realistic.
• There are risks associated with any type of surgery and patients should be informed of these and their surgeon’s success rates when considering procedures.
• It is important that patients are given time to consider their options. Doctors should also inform patients about alternative treatments that may be available.
• Before procedures are carried out, it should be clear who will be financially liable for the correction of any complications.
• There may be some merits to adopting a regulation system similar to that in France. Under this system, patients must be given information on costs, risks and the surgeon’s qualifications to perform their selected procedures.
• The way that cosmetic surgery is marketed should also be regulated.

What is the problem with plastic surgery marketing?

Mercer says that cosmetic procedures are often marketed using special offers, including vouchers, two-for-one deals and surgery holidays, and that these practices contribute to an “unregulated mess”.

The articles also feature a call to ban advertising of cosmetic procedures, stating that, like tobacco, there should perhaps be a Europe-wide ban on advertising all cosmetic surgical procedures, including on internet search engines. While advertising can be powerful, says Mercer, it is often misused by the cosmetic surgery industry and misinterpreted by those it is aimed at.

Where can I find more information on reputable plastic surgeons?

The British Association of Aesthetic Plastic Surgery is a not-for-profit organization based at the Royal College of Surgeons. It was established to advance the education and practice of cosmetic surgery for public benefit. While it is not a regulatory body, it has long been involved in giving the public information on the safety of cosmetic surgery.

Its research into cosmetic surgery tourism was discussed at a recent conference and its press releases highlight a number of dangers associated with unregulated procedures, including DIY injectable treatments available over the internet.

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An estimated 100,000 cosmetic surgical procedures are performed in Britain each year, many by doctors who have had no specialist training in cosmetic surgery. In addition, hundreds of thousands of non-surgical procedures are done, including Botox for wrinkles and laser treatments to rejuvenate skin, many by non-medical staff with little or no training.

The 200-member Baaps represents the top surgeons in the business who performed 34,187 surgical procedures in 2008, twice the number in 2004. More than 90 per cent of them were on women. The most popular procedure was breast augmentation, demand for which rose 30 per cent last year.

But Mr Mercer, who combines private practice as a cosmetic surgeon specializing in facelifts with his work as an NHS consultant in reconstructive surgery for cancer patients, said the market for cosmetic surgery, of which Baaps surgeons account for less than one third, was an “unregulated mess”.

He added: “There has been a massive increase in plastic surgery marketing, including discount vouchers, two-for-one offers and holidays with surgery. In no other area of medicine is there such an unregulated mess. What is worse is that national governments would not allow it to happen in other areas of medicine. Imagine a two-for-one advert for general surgery. That way lies madness.”

Mr Mercer, in the journal Clinical Risk, which publishes articles on cosmetic surgery today, he warns that “the doctor’s first duty to protect the patient” has been forgotten in the headlong rush to cash in. “The motive for performing any procedure must never be financial gain … if we cannot self-regulate then regulation will eventually be imposed.”

Citing experience in France, where all advertising of cosmetic procedures is banned, he says: “Perhaps, like tobacco, there should be a Europe-wide ban on advertising all cosmetic surgical procedures, including on the internet search engines.”

Among those who can testify to the dangers is Jill Saward, the former lead singer of 1980s group Shakatak, who last year agreed to a facelift in the hope of reviving her career after her divorce. But she suffered complications aggravated by her high blood pressure and bitterly regretted the decision. Three months after the operation she still did not have full feeling and was warned full recovery could take a year.

“Surgery is not a quick-fix solution,” she said. “The simple truth is that I could have died. I was an idiot, I should have thought much more carefully about the operation and its dangers. It was pure vanity.”

Foad Nahai, president of the International Society of Aesthetic Plastic Surgeons, backed Mr Mercer’s warning, and called for tougher regulations to prevent doctors practising without specialist training. A code of practice backed by self-regulation of cosmetic clinics was announced by the Government in 2007. Clinics are also subject to inspection by the Care Quality Commission. But Baaps says the measures do not go far enough.

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