Safe delivery of plastic surgery

12th September 2011


Today marks the start of Patient Safety Week, a campaign to encourage individuals and healthcare organisations to be more aware about patient safety. All surgery has risks of unexpected consequences or complications, so what measures can prospective patients take to ensure their safety?  

The risks to surgery must be understood in general and specific terms by any prospective patient. Any surgeon can show their best results, but patients should ensure that they would be able to cope with a disappointing or poor outcome.  There are no guarantees in surgery and it is important to minimise risk by working with a surgeon and hospital that will do their best to support the patient whilst working to correct any problem experienced.

There are considerations for the prospective patient at each stage: choosing the surgeon, choosing the clinic where the procedure is to take place and evaluating the consultation.

The surgeon

Chosing a competent surgeon is paramount. There are many self-styled experts in surgery, some of whom may not even have surgical training or qualifications.  This area is very poorly regulated and, by an ironic turn of events, the burden of regulation falls upon those best qualified.   

That is to say that if a person is not working in a properly governed institution, or is not even registered as a surgeon, he or she may not be subject to regulation and scrutiny in their practice.  

By way of example, I have given opinions on cases conducted by a surgeon who did not have any formal training and had simply served a brief period as a military doctor during a conflict in a tropical country.  He had never been taught, let alone practised under supervision as a plastic surgeon or any other sort of surgeon.  He was in partnership with another doctor who had been suspended by the General Medical Council (GMC) but continued to practise. That doctor argued that he was no longer subject to the regulations of the GMC as he was no longer registered with them, and that as long as he did not misrepresent himself to patients he was breaking no law!  Although I would need to clarify this with lawyers, my understanding is that he is technically correct in this matter.

Another case I once complained about was that of a travelling surgeon who visited the UK conducting clinics in hotel rooms. I was told as he was not registered in the UK the GMC could do nothing about it, and as the patients travelled abroad for surgery he was committing no crime in this country. Clearly like many practising in the shadowy fringes of this world, these people were unaccountable.

However, it should be said that there are many excellent, well-qualified surgeons undertaking cosmetic surgery, and the trick is to identify them and feel confident in your choice of surgeon. So what are the clues?

Firstly the surgeon should be on the specialist register of the GMC in the appropriate specialty (note, not just registered but registered as an appropriate specialist).  For almost all cosmetic surgery, registration as a plastic surgeon would be desirable, although for some specialist areas other registrations can also be adequate (for example maxillofacial surgery for face-lifting, ENT surgery for rhinoplasty).

If the surgeon you have found is not on the specialist register you should exercise great caution and seek to understand why not.  At that point you may find that they do not even have a surgical qualification.  In this country a fellowship of a Royal College is the hallmark of a surgeon in general terms (it says nothing about their specialisation but ensures they have received a surgical training of some sort). So look for FRCS, which may also be qualified by letters indicating where it was earned (England, Ireland or Glasgow or Edinburgh) or more recently what sub-specialty area it refers to.  For European surgeons the situation is less obvious, and here the GMC registration is paramount: to get onto the GMC specialist register they will have to have convinced the GMC that their European qualification has equivalence to a UK qualification.

Some surgeons come to the UK for brief periods working for commercial clinics.  This itinerant practice is worrying: a surgeon rooted in the medical landscape of his area is accountable through reputation and registration.  A visiting surgeon is unknown and less easily accountable. It is always advisable to discuss your choice of surgeon with your GP. It used to be felt that GPs were disapproving of cosmetic surgery and patients did not want to take up valuable GP time with these enquiries.  However in my experience GPs prefer to be consulted. They often have useful advice about the choice of surgeon or institution and timely advice may prevent serious future health consequences.  In any case surgery is a health intervention and like all such treatment your GP should be at the centre of the process for you.

Having said that, many patients find surgeons through word of mouth, and this can be a useful tool.  Similarly, the first face-to-face consultation will tell you a lot about your surgeon, and here it is important that you have trust in him or her and that their behaviour is appropriate.

Two other useful tests of a plastic surgeon’s credentials are that he or she holds, or has held an NHS consultant post and he or she is a member of BAPRAS.

NHS consultant posts are only offered to those who have completed specialist surgical training and are in good standing.  Hard to obtain, they remain the hallmark of surgical competence in the UK, although many surgeons are now relinquishing these posts for full time independent practice as the NHS changes progressively.

Full membership of BAPRAS is also hard to obtain and to become a full member a surgeon must be in good standing, have completed the appropriate training or equivalent and be vouched for by two other recognised fully-trained and accredited members.  This is a very hard hurdle to cross and is a mark of surgical attainment.  BAPRAS is the designated specialty association with statutory duties for training and accreditation in plastic surgery and reports through a complex mechanism to the Royal Colleges in its defined roles.

The clinic

In my dealings with patients and when giving evidence for courts or regulatory bodies I have come across some shocking practices, ranging from surgery carried out in a basement kitchen to home-visit surgery carried out in the patient’s own bedroom.

Clearly neither situation is acceptable but it remains astounding what patients can be persuaded to accept by apparently plausible practitioners!  

In general, whilst there are some single-specialty clinics that can undertake minor procedures very safely, there is no doubt that the greatest safety comes from surgery in a fully competent, surgical environment provided by a well-staffed, multidisciplinary hospital. I prefer to conduct surgery of any complexity in a hospital with a critical care unit (as a safety net) and a range of specialties, which allows for a broadly qualified nursing establishment and easy access to good medical care if ever needed.  This comes at a price but generally these hospitals, often run by large, national chains of providers, do not charge fees significantly higher than the less well-equipped clinics.

Any provider clinic or hospital should take on the responsibility of care for a patient after surgery, so that they are free to return and can easily access care if they experience complications such as wound infection, bleeding or wound breakdown. This raises the important point that clinic groups that recruit patients in one area but offer surgery at a remote hospital in another area are unlikely to be able to meet these responsibilities easily.  My experience is that whilst this is clearly at its worst when patients travel abroad, even travelling within the UK can make competent aftercare of complications problematic and unsatisfactory. Many plastic surgeons can tell stories of having to pick up the pieces of failed care in this respect, with patients desperately seeking help when they are unable to travel to the original site of surgery.  Although such complications are the exception rather than the rule, adequate care may mean daily visits to a hospital environment with access to full lab facilities: clearly impossible if the hospital is 70 miles away and the patient unwell.  

All patients should establish at the outset where such care would be provided, and by whom, and whether it is included in a “fixed price” cost for the initial surgery.  This is how it should be so that patients are not worried about complications or have a financial barrier to those complications being adequately treated.

The consultation

A consultation should be exactly that. The patient should be seeking the advice, the counsel, of the professional, who in turn is obliged from the outset to act in the patient’s best interests. These values may seem to some almost archaic but they underpin all of medicine and cosmetic surgery should be no exception. Patients should therefore be very wary of a surgeon who they feel is trying to sell a procedure, and they should certainly not accept a consultation with someone who is not the prospective surgeon, as seems often to happen in some of the more commercial clinics.

Free consultations are a bone of some contention.  In my opinion and those of many surgeons they represent an inducement to the vulnerable patient, and a true consultation with a professional should attract a fee.  I and many surgeons disapprove of free consultations, advertised discounts, two-for-one packages etc that can induce a patient to seek surgery under clouded judgement.

During the consultation both patient and professional are evaluating each other and complete openness on both sides is vital to a successful outcome.  Here we should note that a “successful outcome” might be not to proceed with surgery, if that were the best advice in the circumstances. My personal view is that rather than asking for a particular operation as some patients do, say after exposure to a television programme, it is better to identify what concerns you and ask how best to tackle that concern. Surgery is not always the best solution and, where it is, there may be different surgical procedures worth considering and discussing.

In turn the surgeon should be open and honest, explain the options available and the attendant risks and not in any way persuade the patient.  Photographs may be useful although now with strict data protection laws these can by difficult to provide.  What is not useful is to show only the best results.  Photographs should show representative results including where appropriate less satisfactory results if these truly represent the surgeon’s experience, for instance the range of scar types that can occur.  It is vital to ask whether a patient could cope if they were unfortunate enough to gain a poor scar or poor result in some other sense.

Finally, the surgeon should summarise the consultation, provide some written material for the patient to consider at home and offer a follow up consultation before making a final decision. It is by contrast appropriate for the follow up consultation to be free of charge so that there is no barrier to the patient returning with questions to clarify.

The most satisfactory consultation will end with the patient meeting staff that will care for him or her, and being offered the opportunity to see the ward or facility where they will be treated.  In some circumstances it may be possible to meet patients who have gone trough similar treatment, although this can be difficult to arrange whilst maintaining confidentiality, especially in a small community.

In summary:

When choosing a surgeon:
•  Look for the surgeon to be GMC specialty registered in plastic surgery or an appropriate other specialty
•  Look for FRCS accreditation if they are a UK surgeon
•  Ideally look for the surgeon to be a member of BAPRAS
•  Ideally the surgeon would hold an NHS post or have held one
•  Beware visiting surgeons who are not known in the local medical or surgical community, they are far less easily accountable
•  Discuss your choice of surgeon with your GP

When choosing a clinic:
•  The greatest safety comes from surgery in a fully competent surgical environment provided by a well staffed, multidisciplinary hospital
•  Ensure 24-hour access for medical care with the back-up of critical care if you are considering a major procedure
•  Choose as local a clinic as possible to eliminate any problems should you require aftercare
•  The clinic should be a competent provider of surgical services registered with the Care Quality Commission

Evaluating a consultation:  
•  The consultation should be a proper quest for the best advice from a surgeon acting in the best interests of the patient
•  The consultation should be with the prospective surgeon
•  Free consultations, discounted care, two-for-ones etc. suggest an element of inducement that could cloud the judgement of a patient
•  A surgeon should show representative images, and not influence the patient with promises of perfection that is not always achieved!


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