Abstract
Cosmetic or aesthetic surgery is defined as ‘operations or other procedures that revise or change the appearance, colour, texture, structure or position of bodily features to achieve what patients perceive to be more desirable’. It differs from reconstructive surgery in that patients do not suffer from surgical pathology, but come to a surgeon desiring alteration of appearance to achieve an improvement. It has been said that cosmetic surgery patients differ from those presenting to other surgeons, in that instead of hoping that they do not need an operation, in cosmetic surgery the wish to undergo surgery is the patient's primary motivation for the consultation.
There are distinctive risks in cosmetic surgery. The focus is on an individual surgeon, rather than a system of institutional care delivery. The surgeon's assessment and selection of patients is crucial to the avoidance of subsequent dissatisfaction. Mainstream surgical training concentrates on the acquisition of knowledge and technical competencies: the cosmetic surgeon's armamentarium must include in addition superlative communication skills and a degree of psychological awareness which will allow exclusion of those patients for whom it is unlikely that satisfaction can be achieved. It may circumvent disaster for the surgeon to say ‘no’.
Awareness of inherent clinical risks and the ability to manage them are crucial to successful practice, as is the surgeon's commitment to support and encourage the patient throughout the entire process. There is, however, the potential for extremely high levels of satisfaction for both surgeon and patient if pitfalls are avoided, and risks are managed appropriately within a positive doctor–patient relationship.
Cosmetic surgery ‘comprises operations or other procedures that revise or change the appearance, colour, texture, structure or position of bodily features to achieve what patients perceive to be more desirable’. 1 Clinical risks are defined as the potential for injury, ill-health or other detriment being caused to patients or staff arising from hazards in the care delivery system, or errors in the delivery of that care.
The surgical background to clinical risk
Clinical risk: reconstructive vs. cosmetic surgery
Risk management in the context of public health provision, such as the National Health Service in the UK, can be described as ‘the systematic identification, assessment, prioritisation and reduction of risk to patients, staff and members of the public’, 2 intended to minimize occurrences of, and to adequately manage damaging events in the healthcare system, in which ‘the culture, processes and structures are directed towards realising potential opportunities whilst managing adverse effects’. 3
Within a large organization, ‘risk management proactively reduces identified risks to an acceptable level by creating a culture founded upon assessment and prevention, rather than reaction and remedy’. 4 Such principles encourage an objective focus on the entire institutional process of care.
By contrast, in cosmetic treatments the focus is always on an individual patient, and their subjective perception of the outcome. The patient's concerns centre on a particular surgeon, and an ‘adverse event’ might be the failure of that surgeon's intervention to meet expectations, rather than the occurrence of physical harm.
Adverse surgical events
An adverse outcome within reconstructive surgery is an incident in which a patient is unintentionally harmed by medical treatment. It is normally considered that an organizational investigation after such an event which considers only actions or omissions of individual clinicians is incomplete, even though it is recognized that ‘human decisions and actions play a major part in nearly all accidents’. These actions have been described as ‘active failures’ and ‘latent failures’. 5
‘Active failures’ may give rise to immediate adverse consequences and are characterized as Action slips, or failure of action, such as picking up the wrong syringe; Cognitive failure, such as memory lapses and mistakes through ignorance or misreading a situation; and Violations, which are deviations from safe operating practices, procedures or standards.
‘Latent failures’ arise from wrong decisions, which may have been taken outside the workplace. In medical practice, these may result from managerial decisions resulting in, for example, heavy workloads, inadequate knowledge, experience or supervision of staff, a pressured working environment and incompatible goals such as conflict between cost and clinical need.
Whatever the balance between the organization and the individual, ‘Accidents hardly ever happen without warning. The combination or sequence of failures and mistakes that cause an accident may indeed be unique, but the individual failures and mistakes rarely are.’ 6
Communication and consent
The surgeon's assessment, selection and empathy with patients who elect to undergo cosmetic surgery are crucial to ensuring that informed consent is obtained, that expectations are realistic, and that the surgical goals are achievable.
In clinical practice generally, ‘the condition from which the patient suffers is the most powerful direct predictor of clinical outcome’. Factors, such as the patient's language and personality influence the effectiveness of communication, and the ‘personality, experience and training’ of medical staff will also be of importance in creating confidence. 7 The candidate for a cosmetic procedure does not suffer from surgical pathology and the decision to undergo elective treatment in the hope of achieving an enhancement of appearance, despite the risk of complications, makes cosmetic surgery ‘a heroic endeavour’ for the surgeon. 8
The Framework for Cosmetic Surgery provision in the UK
A Select Committee was established in parliament in 1999 to review the need for tighter regulation of private healthcare in general, and especially cosmetic surgery. The Committee's recommendations culminated in the Care Standards Act 2000, 9 (enacted on 1 April 2002). Any surgeon practising cosmetic surgery has to be on a specialist surgical register, following training in Britain, or with training recognized by the GMC. (Cosmetic Surgery is not in itself an independently recognized specialty in the European Specialist Medical Qualifications Order 1995, 10 and thus has no specialist surgical register.) The Act allowed medical practitioners who were in independent cosmetic practice prior to that date to continue.
The Chief Medical Officer's concerns about patient safety and the quality of care resulted in the formation of The Cosmetic Surgery Interspecialty Committee by the Senate of Surgery of Great Britain and Ireland. Its remit was mainly in the education, training and assessment of practitioners undertaking cosmetic procedures, guidance on standards, advising on competency issues within the regulations of the National Minimum Standards for Independent Healthcare and the development of a framework for procedure specific accreditation.
The Healthcare Commission (which in April 2009 became the Care Quality Commission) reported in 2005 11 that cosmetic surgery lacked a contemporary definition, and that structured and dedicated training was needed, with enhanced accreditation. They found that 63/784 (6%) surgeons practising cosmetic surgery at that time were not on any Specialist Surgical Register.
In January 2005, the Expert Group on the Regulation of Cosmetic Surgery also reported to the Chief Medical Officer, making recommendations on Professional training, development and accountability, non-surgical cosmetic procedures and public education. 12
Following these reports, an independent and authoritative British Academy of Cosmetic Practice is being formed, with the aims of promoting high quality and safety in cosmetic surgery and medicine, while defining the minimum content of a professional benchmarking portfolio based on specific criteria for qualifications, training, and experience. Separate membership categories will exist for surgeons, non-surgical medical practitioners, dentists and registered adult nurses, who will voluntarily apply for entry to a list of recognized practitioners held by the Academy, having satisfied entry criteria, and maintaining registration with appropriate statutory medical, dental or nursing authority. Continuing membership will be supported by appraisal and validation.
Specific concerns in cosmetic surgery
Patients' expectations
Potential patients' expectations are influenced by the media. Television makeover programmes tend to trivialize the hazards inherent in surgery. 13 The advertising to the public of cosmetic surgery by competing commercial providers, has encouraged a consumer focus and emphasized benefits over risks, possibly fostering a limited understanding of the implications of surgery. While information must be provided by the surgeon to prospective patients, there is also a grey area between advice and advertising. 14
At the outset of the clinical relationship, the surgeon should actively seek to understand the patient's concerns, in order to establish whether it is likely that eventual satisfaction can be achieved. Many patients initially have limited or inaccurate knowledge, and should be encouraged to inform themselves from unbiased information sources, such as the website of the UK Department of Health, 15 which offers an A–Z list of procedures and deals with frequently asked questions.
Patient selection
Much patient dissatisfaction results from failures of communication and patient selection. 16 Attempts have been made to teach these skills, for example through the use of standardized patients, played by actors given specific character descriptions. 17 It has also been suggested that the plastic surgeon should integrate a well-developed psychological understanding of the patient into routine clinical practice, in order to attain improvements for the patient that surgery alone cannot achieve. 18 Over their professional careers, surgeons should strive to improve their psychological skills as much as their surgical technique. 19
Patients vary in their subjective responses. The same feature may cause one person immense distress, but another person may find it acceptable and within the range of ‘normal’. This has been characterized as ‘aestheticality’. 20 Thus, ‘… the application of cosmetic surgery should be judged not on the grossness of the abnormality, but on the degree of emotional distress that the abnormality of appearance produces. Cosmetic surgery is psychotherapeutic.’
Taking an adequate history is crucial to enabling the surgeon to understand the patient's expectations. The mnemonic ‘SAGA’
21
reminds the surgeon to elicit specific details of the patient's
Contraindications to surgery have been exhaustively listed.
21–23
The patient's appropriateness of manner, apparent lack of understanding, body language, negative experience of previous surgery and the lack of specific SAGA indications should alert the surgeon to potential dissatisfaction. The acronym SIMON
24
is a ‘red flag’ which warns of potential problems in the
If the decision is taken to proceed, the surgeon must enjoy the patient's confidence. A proper understanding of the procedure, and trust in the surgeon leads to an acceptance of possible problems, in the knowledge that the surgeon will continue along the patient's pathway until complications have been satisfactorily dealt with, and the most favourable result (that is realistically possible) has been achieved.
Professionalism in cosmetic surgery
Medical professionalism is ‘a set of values, behaviours and relationships that underpin the trust the public has in doctors’. 25 In the UK, the GMC's Guidance sets out the general principles and values on which good practice is founded include the obligation to comply with overriding duties and principles, and to explain and justify all actions taken. 26
Beyond the general aspects of surgical professionalism, ‘It is the patient's right to expect that those of us who practise cosmetic surgery develop sufficient surgical experience so that we … consistently achieve excellent results in the majority of our cases’. 8 It is also essential that surgeons are aware of, and are able to deal with ‘…the many traps and pitfalls that are always present and ready to ruin the most meticulous surgical procedure’ 27 by being able to call on adequate training and expertise in their chosen field of specialized interest.
Where should surgery be undertaken?
In the USA, it is recognized that office-based procedures are associated with a 10-fold increase in the risk of serious injury or death as compared with an ambulatory surgical facility. 28 The American Society of Plastic Surgery has issued a Practice Advisory note relating to patient selection, examination and history-taking. Necessary preoperative investigations should be undertaken, and the procedure undertaken in an appropriate and accredited facility which fully meets provider standards. 29
In the UK the premises in which surgery is undertaken must be registered with the relevant Healthcare Commission in England, Scotland, Wales and Northern Ireland. Premises providing cosmetic treatments in England are registered with the Care Quality Commission, the independent Healthcare Regulator for England 30 since 1 April 2009.
Postoperative surveillance
Complications occur in the most competent hands. Patients will in general put up with complications if they have been warned about their possibility (though it is sometimes necessary to remind them that there was prior discussion), and if the eventual result is acceptable. Misfortune may not be avoidable, but the margins for error are slim when patient expectations are high.
It is essential that patients should be followed up appropriately so that complications can be identified, acknowledged, explained and treated. Technical errors which lead to poor results should be acknowledged and corrected.
Patients who are dissatisfied may express their unhappiness in an emotional manner, through signs of anger, disappointment or frustration, even if they are unable to find the words to articulate their concerns. 31 Despite any personal feelings of negativity, the surgeon should ‘listen carefully, provide support and reassurance’. It is important to assure the patient that the surgeon ‘understands the problem, knows how to handle it, and is committed to help resolve it’. Personal attention from the surgeon and staff, and open access for the patient to the surgeon, even after hours, is helpful in fostering a positive relationship.
It may be helpful to offer a second opinion before one is requested, with a willingness to communicate with another surgeon in an honest and open manner, sharing clinical documentation, photographs and the results of investigations.
The loss of a patient to follow-up should ring alarm bells – if the patient does not return for review, the surgeon should make active contact both with the patient and the referring practitioner, and document these communications in the notes in case there is contention, or legal action at a later stage.
Litigation
The potential for malpractice litigation in cosmetic practice may mean not that the surgeon failed to act according to established medical standards, or that the patient was injured, but ‘more and more frequently … an outcome that is less than the patient expected’. 8
Gorney has stated that in the USA ‘well over half of malpractice claims are preventable. Most are based on failures of communication and patient selection criteria and not technical faults.’ He goes on to say ‘The ability to communicate clearly and well is probably the most outstanding characteristic of the claims free surgeon’. 32
The grant of hospital-practising privileges in the UK includes the requirement for adequate indemnity, and should the possibility of litigation arise it is advisable for the surgeon to seek early advice, based on full disclosure of the facts in an atmosphere of openness and honesty.
Conclusion: Giving support, achieving satisfaction
An indication of a consumerist approach to aesthetic surgery is the Internet discussion on whether plastic surgery outcomes should be guaranteed. 33 A surgeon has responded that the things a properly trained and honest surgeon should guarantee are: ‘To listen properly, examine carefully, be honest and fully informative so the patient can make genuinely good choices. To explain all the bad stuff including “you might die from a pulmonary embolus” … To do the very best they can, all the time, in all cases. To be there if there is a problem and to try their best to fix it. To never give up… And then: you do your best, and occasionally patients suffer complications. But they will have understood that this was possible, and know that you will get them through it.’
Ideally, the experience and outcome of aesthetic surgery should be ‘satisfying and rewarding for the surgeon’. Patients should feel that ‘they are among friends’ and are being cared for within a ‘long-term and trusting relationship’. 34 This fosters the highest levels of patient satisfaction, resulting in a positive experience for both patient and surgeon.