One of the sessions I attended at the 15th Annual Scientific Meeting of the Indonesian Association of Plastic Surgeons in Balikpapan was on patient safety. It is incredible to think that the WHO is having a global initiative on safe surgery with the number one goal being to reduce the number of operations performed where the surgeon operates in the wrong site or on the wrong side of a patient.

I was asked to speak on patient safety in high risk surgeries of plastic surgery.  Inevitably the discussion came round to the question of potential conflicts of interest in private surgery where money is the key issue.  Private plastic surgery, particularly cosmetic surgery, is undertaken as a business.  This will obviously increase the pressure on surgeons to take short cuts to reduce expenditure and perhaps add to patient risk by not over investigating in order not to deter patients. 

The death of rapper Kanye West’s mother in the States underlined the risks of plastic surgery. Of interest was the comment that the patient had apparently consulted another surgeon, Dr Andre Aboolian, who insisted she get medical clearance before he would agree to operate. He never heard back from the patient. 

But is it just in Hollywood and Beverly Hills that such tragedies occur? Sadly not. Just two weeks ago in the intensive care unit of one of Hong Kong’s public hospitals, a 24 year old girl was taken off life support.  She had been declared brain dead two days before.  Two weeks before she had been a healthy young lady who had decided she wanted larger breasts.  She suffered a catastrophic reaction whilst having an anaesthetic injected in a private clinic.

There will be a coroner’s inquest but the account so far ostensibly has a similarity to another death which occurred in a private cosmetic clinic in 2003. 

Cosmetic surgery is not regulated in Hong Kong.  It should be.  In Singapore, the situation appears to be somewhat different. The Ministry of Health suspended the activity of a clinic after the death of a patient undergoing liposuction.

This was ordered under the private hospitals and medical clinics act.  This act governs the operations of private hospitals and clinics in Singapore.

Meanwhile in the UK, the President of the British Association of Aesthetic Plastic Surgeons, Nigel Mercer, recently spoke to the BBC to explain why regulation of cosmetic surgery in the UK was vital. Nigel was described as a ‘top cosmetic surgeon,’ but first and foremost Nigel is a plastic surgeon.  We were colleagues together in Bristol and Nigel’s particular area of expertise in the NHS is cleft lip and palate repair.  To achieve his excellent results,  Nigel, as a plastic surgeon, has had a long and rigorous training in the aesthetic principles of surgery and applies these to a congenital defect.  When these same principles are applied to a person who presents with some concern that would fall within the spectrum of normality the surgery involved would fall into the category of cosmetic surgery. 

Herein lies a problem that again appears to be of a global nature.  How do you regulate something when you do not know or understand what it is?  Reporting on the tragic recent death is Hong Kong one of the local Chinese papers reinforced this concern.  For those whose Chinese is not quite up to scratch the final paragraph of this report reads as follows,

The Hong Kong Medical Association: There is no specialised training for cosmetic surgery in Hong Kong

Nowadays, it is not uncommon that Hong Kong registered doctors perform cosmetic procedures.  Dr Chan Yee Shing, Alvin, one of the vice presidents of The Hong Kong Medical Association, said that there is no specialized training for cosmetic surgery in Hong Kong. 

Doctors just learnt the breast augmentation, double eyelids, etc by other informal ways.  He also said the market for cosmetic and beauty treatments is very big.  For many years, some dermatologists have practised in the cosmetic market.  In recent years, many doctors in different specialties also joined. 

The quality of service provided is not guaranteed due to the  lack of established qualifications.  He explained that local anaesthetics also have risk.  Doctors who do minor operations need to bear responsibility if the surgery is unsuccessful, even though the patient has signed a consent.  The HKMA stated that it is appropriate to give relevant restrictions to the cosmetic surgeons.

It will be difficult in Hong Kong and indeed in the UK to regulate cosmetic surgery until and unless the relationship between cosmetic surgery and plastic surgery is fully appreciated.

Plastic surgery is a specialty that incorporates a collection of skills, expertise, and techniques based on a foundation of aesthetic principles which are directed towards enhancing the quality of life of patients by effecting a positive change in form and function. 

When the patient presents with some deficiency or abnormality (for example secondary to trauma, or tumour excision or congenital absence or loss), the plastic surgery performed is designated reconstructive plastic surgery.  When the patient presents with form and function which fall within the spectrum of normality, but the patient wishes to enhance and redefine their normality, then the plastic surgical application is termed cosmetic plastic surgery (1).

So if plastic surgery is the name of the coin, reconstructive surgery and cosmetic surgery are the names of the two faces.

To conclude, cosmetic surgery is an integral part of the specialty of plastic surgery.  Unregulated, it is potentially deadly.  With appropriate regulation, money will be less of an issue and Nigel Mercer puts it very well, I quote:

‘The safety of the patient must be a doctor’s first and foremost consideration.  There are safe ways to practise, which should be followed, and the profit motive should not come into the patient safety equation.’

Ref.

1.         Burd A.  Plastic Surgery, Body Image and the Blind.  JPRAS 2007;60:1273-1276.

Competing interest statement: I have an academic appointment in Hong Kong and as such perform a limited amount of private practice.  The main proportion of the income thus derived supports teaching and research. I was an expert witness in the Coroner’s inquest of the Hong Kong liposuction case referred to in the text but received no fee for this.

Andrew Burd is professor of plastic, reconstructive and aesthetic surgery at the Chinese University of Hong Kong. His major clinical interests involve paediatric burns care and the role of plastic surgery in the palliation of advanced malignancy. Academic interests include pragmatic ethics related to the practice of medicine including research and publication.