Definition: Cosmetic surgery means procedures to improve appearance. It is also known as aesthetic surgery.

All trainee plastic surgeons learn the basic techniques of aesthetic surgery and this should be regarded as intrinsic to plastic surgery. Much of so-called cosmetic surgery, for example the correction of gross nasal deformity, protruding ears or major breast hypertrophy, can enormously improve the patient's quality of life and should be available under the National Health Service. Tattoos are a particular problem in that they tend to be inflicted on young people who bitterly regret them later in life when they may restrict employment opportunities. Treatment is often therefore economically worthwhile and may also aid in the rehabilitation of offenders.

There must be a full clinical assessment of the patient by the general practitioner, the plastic surgeon and, where appropriate, a psychiatrist or psychologist. It should be recognised that many of these patients are deserving and should have the opportunity of surgery as there is significant social, psychological and physical benefit to be gained. However, at present aesthetic surgery on these grounds is perceived as low priority. Surgery carried out purely for beautification or rejuvenation cannot be justified within the National Health Service.

In some units, patient assessments have been carried out to test the change in Quality of Life following plastic surgical procedures. The resulting numerical scale of Quality Adjusted Life Years or QALY scores gives surgeons and managers a measure of the post-operative benefit gained from procedures that have a major cosmetic component. Guidance on patient selection and priority for treating these patients is essential.

Current moves to exclude or remove patients seeking aesthetic surgery from waiting lists are to be deplored. The British Association of Plastic, Reconstructive and Aesthetic Surgeons is working towards priority setting and patient selection together with a review of outcomes. The proliferation of self-styled cosmetic surgeons, without accreditation in plastic surgery or in one of the other major surgical specialities, is not likely to be in the best interests of the patient, but if NHS trainees are denied the opportunity of a variety of aesthetic surgical experience, this will be the result. Furthermore, the inevitable decline in the standards of private cosmetic surgery could lead to referral back to the NHS of patients for corrective re-operation and/or long-term treatment.

There should be opportunities for surgeons and managers to work together in examining all aspects of the aesthetic/therapeutic debate, and the legitimacy of such treatment, given the constraints of a cash-limited system, should be recognised. Open discussion can only be of benefit to all concerned.

The issues of patient selection and priorities throughout the National Health Service must be addressed. Collaboration between clinicians and managers is essential. Guidelines for the purchasing of aesthetic surgery has been produced for the West Midlands Regional Health Authority by clinicians and managers.

Other studies emphasise the psychological benefit of low priority, aesthetic plastic surgery.