Surgeon News - Case for Inclusion

06 April 2017

Mark Henley makes the case for the inclusion of cosmetic procedure training in mainstream surgical practice

Cosmetic surgery is often regarded as being a dubious area of surgical practice more closely related to the beauty parlour than the hospital. It is perceived by many as being the indulgence of the vain by surgeons more interested in financial gain than the ethical application of their skills and something built on junk science and hype.

There is an element of truth in all of the above as practices vary widely and are frequently driven by commercial pressures and a desire for short-term gain. There is no formal regulation or recognized standards of practice other than on an individual case basis when matters reach the courts or the GMC. However, there is significant potential to benefit patients and surgery by inclusion of cosmetic procedure-specific training in mainstream surgical practice.

In all areas of surgical practice, a critical element that both the patient and surgeon bring to their relationship is vulnerability. The patient is vulnerable to their condition and to their fears that the surgeon may not provide sufficient skill and empathy; the surgeon is vulnerable because of fears that their performance may be insufficient to cure or palliate or to satisfy the expectations of the patient and the family (Goldwyn R. 1991. The Patient and the Plastic Surgeon, Little, Brown, 1991. p4). A lack of recognition of this by all concerned increases the risks of avoidable adverse outcomes. This is frequently concealed by a combination of commercial and social pressures. Alternatively, an exclusively scientific focus on firm evidence for all interventions is also used to justify them in otherwise inappropriate circumstances.

The vast majority of patients seeking cosmetic surgery are clearly vulnerable and there are well documented incidences of commercial organisations and surgeons seeking to exploit this. Extreme examples of such questionable practices include breast augmentation in pregnancy and breast reductions in patients who are breast feeding. There is also the use of non-refundable deposits to commit patients to surgical procedures. The surgical community has a duty of care to its consumers and the lack of involvement in training and supervision of what is now an established area of surgical practice is no excuse for failure.

One rationale states that training in cosmetic surgery is separate from main- stream practice and should be self-funded. However, where does ‘unacceptable’ cosmetic surgery stop and ‘acceptable’ reconstructive surgery start? A significant proportion of congenital anomalies, post- traumatic deformities and defects following oncological resections have no functional component but few would question whether it was appropriate to train surgeons in such reconstructive techniques.

Led by Professor John Lowry, the Cosmetic Surgery Inter-specialty Committee is exploring ways to legitimise and facilitate training with all interested parties. The majority of organisations directly involved in cosmetic surgery in the UK are members of the Independent Healthcare Advisory Service and are very enthusiastic to see recognised standards of training and practice. They appreciate the commercial value of reducing risk.

The ideal live training setting for any surgical procedure is an elective situation operating on otherwise healthy patients in a controlled environment where all aspects of patient care are addressed, where good tissue handling technique produces positive outcomes, and where the differences between good and poor practice can readily be appreciated. Modular training in particular techniques and procedures is another ideal. Cosmetic surgery offers such an opportunity.

In all areas of surgical practice there is a need for the correct combination of surgeon, procedure, environment, and timing of surgery to achieve the desired outcome. In cosmetic surgery these factors are much more readily appreciated than in other specialties and so it provides a valuable training opportunity for surgeons at all levels and in most specialties in the fundamentals of good medical and surgical practice.

Patients often have unrealistic expectations regarding procedures and outcomes. Failure to assess the patient in a holistic manner and to obtain informed consent rapidly results in feedback with protracted and sometimes uncomfortable consultations with the patient or alternatively protracted and equally uncomfortable consultations with medical defence organisations or the GMC.

The results of cosmetic surgery are readily apparent and cannot be concealed by layers of skin and soft tissue or concomitant conditions. This is an area of surgical practice where tissue handling techniques make the difference between success and failure.

It is now inappropriate for the NHS to fund training in cosmetic surgery but a model has been developed between Nottingham University Hospitals and Nuffield Hospitals which provides training under the NHS umbrella in a cost neutral fashion and which generates income for training purposes. The willingness of patients to pay for training procedures to be undertaken has been established as has the benefit to the employing Trust of reimbursement for identified use of ‘PA’ and training ‘SPA’ time.

If undertaken in a shared fashion, with the trainer performing a variable proportion of the surgery, competence can be confirmed and there is no significant time penalty attached to training procedures thus avoiding any ethical or commercial concerns.

The planning of ‘training time’ in the independent sector enables trainer and trainee to be removed from the distractions of departmental work. When experienced trainees are involved, the training required to achieve basic competence can be apparently short with assistance at three procedures and the directly supervised performance of a further three procedures. However, this amounts to at least 36 hours of one-to-one tuition on a single procedure in addition to the personal study under taken in preparation for the training. This model is also readily applicable to other areas of elective surgical practice.

The potential benefits of including cosmetic surgery in mainstream surgical practice are enormous. For the patient there is improved safety, clarity, and quality of care. For the surgical community, there are the benefits and developments that will flow from the removal of inter-specialty barriers and cross fertilisation between the anatomically based specialties, including ENT, maxillofacial, oculoplastic and breast and plastic surgery, which is based upon the holistic application of surgical principles to individual situations.

Mark Henley
markhenley@doctors.org.uk