Surgeons set new standards for cosmetic treatments

BMJ 2013; 346 doi: (Published 29 January 2013) Cite this as: BMJ 2013;346:f590
  1. Jacqui Wise
  1. 1London

The Royal College of Surgeons has said only surgeons should provide cosmetic surgery and that non-surgical cosmetic treatments should be carried out only by doctors, dentists, and nurses who have had appropriate training. Currently, procedures such as laser treatment or injections of botulinum toxin or intradermal filler can be administered by anyone.

The college has produced new guidelines, Professional Standards for Cosmetic Practice,1 in the wake of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) in 2010,2 which exposed a lack of consistent professional standards in the field of cosmetic practice.

Norman Williams, president of the Royal College of Surgeons, said: “We have serious concerns that not all those who offer cosmetic procedures are adequately qualified or that patients are getting accurate information prior to treatment.”

Most cosmetic procedures are performed outside the NHS. In 2011, 43 000 cosmetic surgical procedures were done by members of the British Association of Aesthetic Plastic Surgeons, and the total number done by all practitioners is thought to be at least three times that figure. The report says there was a 5.8% rise in cosmetic surgery procedures in 2011. No figures are available for non-surgical procedures, but these are also growing in popularity year on year.

The new guidance from the college states that it should be standard practice for practitioners to discuss relevant psychological issues with patients and document any signs of eating disorders or body dysmorphic disorder. They should also consider referring patients to a clinical psychologist before proceeding with treatment.

The standards also state that it should be made clear in advance whose responsibility it would be to pay for any additional care if the procedure did not go as planned. This should include stating that the NHS will not intervene to correct privately provided cosmetic procedures even if the outcome is poor. This follows the scandal that emerged in 2011 over breast implants made by the French manufacturer Poly Implant Prosthèse (PIP), which led to many women demanding that their implants be removed and replaced on the NHS.3

Key recommendations from the guidelines, developed by a working group of surgeons, psychiatrists, psychologists, and dermatologists, include:

  • Only qualified medical doctors who have done postgraduate surgical training should do invasive procedures such as breast surgery or liposuction

  • Practitioners should not imply that a patient will feel better or look nicer after treatment but should use straightforward terms such as bigger or smaller

  • Any guidance should use either accurate diagrams or photographs of real patients, not models or airbrushed photographs

  • There should be a cooling-off period of at least two weeks between the initial consultation and any invasive surgical procedure

  • There should be no financial inducements, such as time limited special offers, which may speed up a patient’s decision to have a procedure

  • Cosmetic practice should be done only in licensed premises with resuscitation equipment readily available. “Botox parties” or “filler parties” in domestic settings should not be allowed.

A Department of Health spokesperson said: “The report from the Royal College of Surgeons is timely as NHS medical director Sir Bruce Keogh is currently carrying out a review into regulation of cosmetic interventions, including cosmetic surgery. The review will be published in March. Its recommendations will be evidence based, with the safety of the patient at the forefront.”

Steve Cannon, chairman of the working party and a council member of the Royal College of Surgeons, told the BMJ: “The NCEPOD report was an accurate reflection of cosmetic practice in the UK, and I don’t think anything has changed since then. The college is not a regulator, but we have set out the standards that we feel should be adhered to.” He admitted, however, that the Department of Health was unlikely to legislate to ensure that cosmetic treatments such as Botox are provided only by those with medical training. “Unfortunately it will be difficult to renege on the decision [to allow non-surgical treatments to be provided by non-healthcare professionals]. It was made without due thought, and the situation is currently a free for all.”

Ian Martin, NCEPOD clinical coordinator, commented: “In 2008 we identified poor regulation, low volume practice, and deficiencies in training. We also identified poor standards of consent and unrealistic advertisements, which had tended to stress the benefits of surgery without dealing sufficiently with potential side effects. The lack of standards and systematic audit was also highlighted. We are very pleased to note that the Department of Health and Royal College of Surgeons are now taking steps to address these deficiencies in cosmetic surgical practice and support the report published today.”


Cite this as: BMJ 2013;346:f590