The world of cosmetic medicine—widely perceived to be closely associated with Marylebone—is populated by a large number of highly skilled and ethically-minded clinicians whose priority is to improve the lives of their patients, but it also has its murkier side. The Journal meets three of the experts who believe that higher levels of regulation and public education are needed to clean up the field
Words: Clare Finney
It was while serving as nursing director at a London hospital that Sally Taber found her calling in cosmetic surgery. What should have been a routine day ended with a liposuction patient suddenly and terrifyingly experiencing a cardiac arrest. “Luckily we got the heart restarted,” she recalls. “But when I asked what the hell happened, it transpired the patient had diabetes, and we’d done liposuction without any risk assessment.” After that, Sally turned the world of cosmetic practice upside down in search of safety measures. “And under every stone I found bad practice. Since then it has become my mission to improve standards of care.”
Today, Sally runs the Independent Sector Complaints Adjudication Service (ISCAS) and the register of the Joint Council of Cosmetic Practitioners (JCCP). She has worked with both Health Education England and the General Medical Council (GMC) on improving the qualifications of, and guidance to, those working in cosmetic care. “Sally has been an amazing zealot for improving standards—particularly on the non-surgical side,” says Mr Simon Withey, a consultant plastic and reconstructive surgeon of serious standing, whose private practice is based in the Harley Street Medical Area. As the current president of the British Association of Aesthetic Plastic Surgeons (BAAPS), he too has “tried to make setting standards a real focus”. And, as is the case with Sally, his work is far from over.
Cosmetic surgery is nothing new. “One of the very first operations in the book was recorded in 1500BC, and involved lifting tissue from the forehead to rebuild the nose,” says Mr Tim Goodacre, consultant plastic surgeon, former BAAPS president and council member of the Royal College of Surgeons (RCS). In ancient India, he explains, cutting off someone’s nose was fairly commonplace—either as a punishment, or to attack a rival. “Ancient healers would rebuild the nose to improve its appearance,” he continues. For all its history, the biggest step change in cosmetic surgery came with the advent of modern anaesthesia, and the remarkable surgical advances born out of the two world wars.
“In the first world war, blasts gave people really nasty soft tissue and bone injuries—often in the face,” says Mr Withey. “In the second, they were dealing with burn injuries to airmen.” Plastic surgery—the catch-all term for both aesthetic and reconstructive surgery—grew out of the need to restore the appearances of these young men. Or, at the very least, to try. “Back then, it was just reconstructive surgery. But after the war people realised they could go beyond servicing an immediate need. It started to evolve beyond reconstructive to aesthetic and cosmetic surgery.” Breast augmentations seem in stark contrast to rebuilding the bone structure of blast victims, yet to dismiss operations like these as mere vanity is “wrong, I think,” says Mr Withey simply. “It dismisses some of the functional issues which are often associated with the patient’s cosmetic need.”
Understanding the patient’s motive
Rhinoplasty is just one example. “The way a nose has grown or developed can affect its functionality,” Mr Withey explains. A nose reduction or reshape that makes you happier about its appearance might also enable you to breathe or smell better; ditto cosmetic breast surgery, which can address “deep psychological problems with body confidence, like undressing in changing rooms or in front of a partner”. Far from mutual exclusivity, the surgeon believes the vast majority of so-called cosmetic cases sit on a spectrum between aesthetic and reconstructive. “There are ones that are clearly purely reconstructive, and there are ones that are purely aesthetic—but the vast majority are in the middle,” he continues. “In order for surgery to be successful, you need to understand the patient’s motives. If you undertake it as a purely technical exercise, without understanding their expectations, it will end in misery.”
Mr Withey is a thoughtful and thoroughly decent clinician. Prior to taking on a patient, he’ll do his level best to understand their needs, and determine if cosmetic surgery is the answer. Sometimes it isn’t: “I probably turn down about 15-20 per cent of patients for surgery because it won’t meet their expectations, or because there are too many risks involved.” Some patients he refers to a psychologist before treating, in order to better understand their motives. “Any aesthetic surgeon who doesn’t have a psychologist who understands cosmetic surgery on speed dial is crazy,” he insists. “It’s one of the most important parts of the job.” If someone has been unhappy for 30 years, “it’s unlikely a short operation will change that. They probably need therapy.”
“When we first set up ISCAS, the first complaint that came in was from a patient who’d had four rhinoplasties. Well, he should never have had the first one,” says Sally. “Whatever shape his nose was, he would never have been satisfied.” A surgeon who had been properly trained would have asked him the right questions and communicated with his GP to get some medical background. “If a patient has just had a divorce, or been bereaved or is on anti-depressants, and approaches you for a face lift, then obviously it is not the right time,” she explains
It is to these ends that BAAPS has established a scheme to educate psychologists in this area. As it stands, “there aren’t many psychologists with a deep understanding of cosmetic surgery,” says Mr Withey, but the group’s aim is to build a network of psychologists around the country to whom surgeons can refer. The RCS, meanwhile, has established a certification scheme for cosmetic surgery practitioners, “the idea being that people who want to practice cosmetic surgery must, as well as showing evidence of proper training and experience, undertake a two-day Professional Practice course,” explains Mr Goodacre. Set up and run by the college, the weekend course covers everything from litigation to psychology, and is “designed to steer people into considering what the specific nuances of managing people with body image problems are”.
Progress is slow
“It is a very good course,” he continues. Surgeons who undertake it are awarded a certificate of cosmetic practice—something to look out for if you or a loved one is considering treatment. “The hope is this will eventually lead to credentials that the GMC will recognise and can be easily looked up by the public—but at the moment this register of certified surgeons is held by the RCS.” You can find the register by visiting the RCS website, but the GMC and the Care Quality Commission have yet to embed it in their regulatory standards. Mr Goodacre believes this will change—“the scheme is gathering pace, and more and more members are partaking”—but progress is slow. “It’s a big world out there, with people running clinics under the radar and going right to the edge of what’s acceptable. We’re making headway, but it is very slow.”
As it stands, regulation in this country is surprisingly below par. “We are much less regulated than other parts of Europe. Here you can call yourself a plastic surgeon if you are just a qualified doctor. There’s no regulation over the title,” Mr Goodacre explains, and indeed, the NHS website confirms that “at the moment, doctors who provide cosmetic surgery independently in the private sector only need to be registered with and licensed by the GMC as a doctor. There is no legal requirement for the doctor to be a specialist surgeon on the GMC’s specialist register.”
To say this is problematic is an understatement. A few years ago, it emerged that tens of thousands of British women had received breast implants made with industrial grade silicon, as opposed to a surgically approved material. “As a result, the then NHS medical director Professor Sir Bruce Keogh commissioned a report into the regulation of cosmetic surgery, and found—to paraphrase him—that it was as easy to buy dermal fillers on the market as it is a ballpoint pen. It was Prof Keogh who commissioned the RCS to set up a certification scheme after realising the scale of the risks that unlicensed, uninsured practitioners were posing to patients. From new machinery with “unsubstantiated claims about melting your fat”, to so-called ‘Ryanair doctors’ who “fly in from other countries and fly out as soon as anything goes wrong”, Prof Keogh found a Pandora’s box of questionable practice in both the surgical and non-surgical parts of the industry.
At the root of the problem is the current beauty ideal: a celebrity-driven, selfie-obsessed culture with a negative attitude towards ageing. Magazines and websites “airbrush images of women and men into perfection disguise the reality of the human body,” Mr Goodacre complains. Sally is particularly vocal about cosmetic surgery disciples the Kardashians, whose influence on Instagram is “totally unacceptable”, she says, enraged. Being more exposed to images on Instagram and online—a recent four-page spread in Grazia on “the best age to have Botox” is just one recent example—it is young people who are perhaps most susceptible to pernicious ideas around body image. “On the surgical and on the non-surgical side the practitioner needs to really question the person. A programme I was on last week on the BBC revealed 22-year olds having cosmetic surgery.” Not only does cosmetic intervention carry risks that, for the under 30s, aren’t worth taking, but the long-term impact of carrying out operations, injections, fillers and so on on such young bodies are unknown—“nor are the NHS likely to invest in researching such things”.
Lasers and fillers
That’s why a register is needed not just for cosmetic surgeons, but for non-surgical practitioners, too: those wielding the laser guns and dermal fillers. “The person we are working with on this new register—called the Joint Council of Cosmetic Practitioners—is Leslie Ash,” says Sally, referring to the actor who found fame in Men Behaving Badly. “She decided she wanted some fillers in her lips, had them done once, and the second time had them done in someone’s kitchen by a doctor from Venezuela. It didn’t go so well.” To her credit, Ash is serving as a patient advocate for the new register, which will cover “five modalities: Botulinum toxin, dermal fillers, chemical peels, lasers and hair restoration,” explains Sally. “And if you are providing a permanent treatment—which dermal fillers are, despite being classed as non-surgical—the standard set will be far higher than if it is for something temporary.”
The JCCP opened in March. Its standards are set by the Cosmetic Practice Standards Authority (CPSA), which in association with the JCCP collects data on adverse incidents and complications. Guidelines on laser and light, providing eye shields for users, the standards of equipment, practitioner training, and so on, “the CPSA sets standards for patients for all of these things,” says Sally. Practitioners need to be appropriately qualified and have sufficient levels of experience—not just for their patients’ safety, but theirs also. “Think of the damage a laser could do if not used properly,” Sally continues. Yet with 90 per cent of what goes on in the cosmetic world falling into the non-surgical bracket, and new treatments being constantly invented, staying abreast of this mercurial industry is no mean feat.
“When people go to buy a car, they research it thoroughly,” Mr Withey points out. “Unfortunately, they don’t seem to think that way about cosmetic surgery.” Indeed, the surgeon recalls an article a few years back which “interviewed several women about how long they took to choose a cosmetic surgeon, and found most decided within just five to 10 minutes.” Of course, the ‘industry’—“I hate that word, we shouldn’t be an ‘industry’,” says Mr Withey—doesn’t help them. “One of the great difficulties in healthcare is that, unlike buying a car, where you start by assuming you’ll be ripped off, you assume doctors will do their best by you; that however much you spend, wherever you are, whoever the surgeon is, they will do you no harm.”
Do your research, ask questions and assess their code of practice, advises Mr Withey. “Of course, patients should be protected against malpractice as much as possible, but they also need to look at standards. They need to find out whether the practitioner is connected with certain associations, and assess what guidelines they adhere to.” Mr Withey feels the commercialisation of his field has “had a pernicious effect on many levels, not least because people believe the outcomes will be the same with any surgeon, so they opt for the cheapest surgeon, or go abroad for surgery.” At the same time, the transactional nature of the exchange can change the patient’s expectations from an operation. “Because they are signing a cheque,” says Mr Withey, “they feel they will get exactly what they are ordering.”
A clear red flag
Of course, surgery doesn’t work like that. This isn’t pedicures or chocolate bars. There may be scars, there may be complications, and satisfaction is by no means certain. “In certain cases, the patient does not want to hear about the vagaries and unpredictability of surgery,” says Mr Withey. “I sense that some patients feel that by paying a fee they somehow buy security, or at least the sense of it. If that sense of security is likely to be rocked by a frank discussion on the limitations and risks, some patients would rather avoid that conversation. For a surgeon, this attitude should be a red flag, signalling a patient who is not ready or well prepared for surgery.”
Mr Goodacre agrees: “You have a vulnerable group of the population, sensitive about their bodies or on a rebound from a relationship and so on, and you have an industry which wants to capitalise on their vulnerability.” In low moments, he finds such ethical complacency “deeply saddening”—not least when coupled with misleading advertisements and an appearance-led culture. Yet while we are all vulnerable to the gold-plated promises of great persuaders and charlatans, there are “within our world some great institutions, who are still trustworthy and operating for the greater good of surgery and society.”
“We’re sitting in one now,” Mr Goodacre smiles, gesturing around the lounge at the Royal College of Surgeons. “The college’s strapline is ‘advancing standards’, and that’s what we’ve been working on.” Sally Taber I meet at the Royal Society of Medicine, another venerable institution; Mr Withey, at his own superbly rated London Plastic Surgery Associates, at the Hospital of St John & St Elizabeth. “The reputable consultants tend to get together. We are all members of the BAAPS, which provides surgeon training, public education and advice to the Department of Health,” Mr Withey smiles. “And we spend a long time and a huge amount of money informing the media.” I for one feel enlightened—and confident that, should I ever come to need cosmetic surgery, I’ll know exactly what to look for, and who to believe.