Improving the safety of aesthetic surgery: Recommendations following a 14-year review of cases referred to the Medical Defence Union from across the United Kingdom (1990–2004)

Introduction

‘First do no harm.’ Hippocrates, fourth century BC

It was a wise Professor of Surgery who asked his medical students where the most dangerous place in a hospital was? After a number of replies, he surprised them by telling them it was the consulting room, as that was where bad decisions were made, which could then lead to medical disaster. So, in the field of aesthetic surgery the consultation is the key to avoiding problems.

The consultation should be carefully documented, including its length, so that subsequent inspection of the notes gives some indication of time spent informing the patient. It is rare that a patient has enough information or understanding following an initial consultation to make their decision and the offer of a second consultation (usually not charged for) should be made and documented. Before embarking on any surgical procedure for want rather than need, as is the case for aesthetic surgery, a thorough assessment of medical history must be made to exclude any significant pathology. Should any medical pathology exist it is helpful to write to the relevant specialist and inform them of the patients request for aesthetic surgery and ask the specialist whether on medical grounds this is safe and whether any precautions should be taken to reduce risk. All such correspondence should be kept on file.

It may seem that performing aesthetic surgery to meet a patient's expectations sounds obvious but a number of claims were successfully made against surgeons where no documentation of the patient's goals were made. In these cases there was discrepancy between what was achieved and what was expressed by the patient. This is particularly so in rhinoplasty, where there are often a number of anatomic goals not all of which can be corrected surgically. As an integral part of the consultation a clear statement of what the patient was hoping to achieve is essential. Concomitant with documentation of the goals is a statement of how realistic these goals are and then, what the agreed correction would achieve. To document the agreed goals is a basic requirement of the medical record and this single factor was the reason why defence of a number of cases failed and therefore required settlement ‘Out of Court’. During the process of consultation the patient is required to understand what degree of correction is realistic and although some of this understanding can be obtained verbally it can be helpful to show representative photographs of before and after shots performed by the surgeon themselves to illustrate what can be achieved. These should not be just the most outstanding surgical result achieved by that surgeon but a realistic result, which the patient can expect. With certain procedures, a full correction is not possible and should not be expected by the patient however an agreed improvement (documented as a percentage) avoids any ambiguity later regarding what was agreed. A typical example of this occurs in necklifting or arm lifts where for anatomical reasons or perhaps skin quality a full correction may not be anticipated. To put in the medical record that an agreed percentage correction (keeping this realistic and conservative) was made avoids any complaint at a later stage which cannot be defended. Far better to under-promise and over-deliver.

Just as important as illustrating the surgical correction is showing the nature of the scarring. A number of claims which could not be defended rested on the patient claiming not to be aware of the degree of scars to expect. The illustration of photographs both of the outcome and possible scars should be shown in the consultation and documented as having been demonstrated in the medical record.

The latest advice on consent by the GMC states that a doctor should, in recommending the benefits of a procedure, provide the patient with information on alternatives. Perhaps the field of facial rejuvenation provides the best examples as non-surgical alternatives for the early stages of ageing abound. A younger patient who comes requesting a facelift but whose complaint is purely for correction of the nasolabial folds may be better served with dermal filler injections than a surgical procedure. Claims to the MDU regarding over-treatment when no surgery or a non-surgical alternative was an option emphasize the need to document a wider discussion of treatment options in certain patients.

A patient undergoes surgery in the hope of improvement, however all surgery carries inherent risk. As patients for cosmetic procedures are ‘normal’ to start with their acceptance of complications or risk is at a lower threshold than other branches of surgery. A full explanation of the surgical risks and some indication of their likely frequency is an essential requirement of the medical record. Not only do risks which occur commonly need to be discussed and recorded but also those which may be relatively rare but of surgical significance. As the majority of aesthetic surgery is carried out on a self-pay basis there could be cost implications attached to a complication and patients must be made aware what the arrangements for dealing with a complication in terms of hospital costs, anaesthetic and surgical costs. Claims to the MDU have been made relating to lack of clarity regarding these invisible costs when patients have had bills which were not explained and documented as such during the initial consultation.

Although separate from surgical risks, the normal recovery and amount of time needed to return to activities; work, sport and socializing need to be clear to the patient. Claims paid by the MDU have included some where the documentation of recovery times was not clear and claim was made that return to work was delayed beyond that which the patient expected. Such claims are difficult to defend in the absence of documented evidence stating recovery and allowing flexibility (e.g. ‘After this procedure, 90% of patients would be back to work in two weeks.’). The statement of a percentage and time allows the patient to make a decision regarding return to work but keeps the situation flexible for the surgeon as this is of course a very individual process.

Part of the initial consultation is the process of examination. Clear documentation of examination findings to record baseline state, asymmetry, scars, baseline nerve function in the region (particularly facial nerve function), skin quality and presence of previous surgery are required. An essential tool to record these is clinical photography. These should be taken from all relevant angles in good light and at a time close to the time of surgery as some features of anatomy change with time such as weight so that a record taken at time of the operation is key. Many claims can be avoided altogether by the simple act of showing the patient their preoperative photograph and illustrating a pre-existing asymmetry which may have gone unnoticed before surgery (as they usually do!).

Many patients retain less than half of the information provided during a consultation. In order that they are adequately prepared for their operation and to show that due care and attention has been paid to achieving this it is good practice to provide some written information on the procedure, what it involves, the recovery and the risks. This can be generic and supplied for example from the British Association of Aesthetic Plastic Surgeons (BAAPS) or individual to the surgeon's practice. Providing such information and recording that it was given ensures that the surgeon has done what is reasonable to prepare a patient for surgery. To absorb this information requires a cooling-off period and it is wise not to book a patient for surgery within two weeks of the initial consultation and as mentioned earlier to offer a second consultation either to answer remaining questions or perhaps as a preoperative consult to check patients are prepared and allay anxiety which usually sets in 2–3 weeks before surgery.

At the time of surgery itself the anaesthetist plays a highly significant role and a number of high-profile cases which have not only led to large claims but also received media attention from aspects of the medical management of the surgical patient. It is wise for a surgeon who performs a significant amount of aesthetic work to have a regular anaesthetist with whom they have a good rapport as they are integral to a successful team. Carrying out preoperative blood tests and an ECG, where indicated, are essential. The hospital in which the surgeon performs the operation should also be chosen carefully. One should work in a small number of hospitals (perhaps only one or two) where nurses can get used to the surgeons techniques and requirements and where these operations and their postoperative care is regularly performed. Just as an NHS consultant post requires that a surgeon should reside within 10 miles or 30 minutes travel of the hospital, so the same yardstick should be applied to aesthetic surgery in the private sector. The concept of the travelling itinerant surgeon who operates and consults some distance from their base has been the reason for a number of claims of negligence and even removal from the GMC register as the duty of care cannot be provided satisfactorily. It is different if the patient has travelled some distance to the surgeon as this was a choice made by the patient and they would be expected to travel to the surgeon for their postsurgical care which is their responsibility. However when the surgeon travels some distance to the patient they are entitled to expect the surgeon to also travel to them in an emergency or for their postsurgical care which may not always be feasible. This point underlines the importance of arrangements for postoperative care itself. The patient must be clear about the follow-up arrangements and what to do in an emergency. There should be a clear message as to what to look out for, who to call if concerned, both at night and day, as well as who will be responsible for covering during periods of annual leave. Being unable to prove that adequate clarity was achieved in this regard has again been the source of a number of claims.

During the period of follow-up it is essential to keep contemporaneous records and note the recovery and any concerns of the patient. Any phone calls made to the patient or other medical colleagues must also be noted carefully as this shows the detailed care which has been given. Many of the problems raised by patients can be easily dealt with if they are seen swiftly and reassured while if they are not, anxiety can lead to aggression and blame. If a problem does arise the surgeon should be honest and see the patient as often as they (i.e. the patient) feel is necessary. Unfortunately we live in a society where blame is apportioned at any opportunity and so it is not unusual for patients following aesthetic surgery to seek blame if their result is not as expected. Much of this can be avoided with careful preoperative preparation and counselling however with any service where significant numbers of procedures are performed it is inevitable that at some time or another patients will make complaints regarding even the most careful, honest and skilled surgeons. Under these circumstances the surgeon's integrity can only be defended with a thorough and documented medical record. It is worth considering the words of Professor John Converse, Chief of Plastic Surgery at New York University in his address to the American Association of Aesthetic Plastic Surgeons (ASAPS) with regards the risk of litigation in aesthetic surgery:

‘But for the grace of God, there go I.’ John Converse, ASAPS Meeting, 1971