Tania Tavares-Pinto 11th January 2018
Plastic surgery is a service and in that respect it falls subject to regulation and an absolute commitment to customer satisfaction.
But cosmetic surgery is still a surgery; despite the somewhat lighthearted attitude often conveyed in marketing campaigns for cosmetic surgeries – where information regarding the seriousness of undergoing procedures is relegated to a footnote at the bottom of the advert. While the risks of something going wrong are very small, cosmetic surgery still remains a serious decision for many of those who consider it.
It’s not only a financial commitment, but one that alters your life, your body, the way you perceive yourself and the way that others perceive you too. In the age of the internet, there’s a wealth of information and prospective patients find themselves approaching cosmetic surgery from a more informed stance and with a wider range of choice in surgeries, clinics, and types of treatments.
But in the excitement of undergoing a procedure, are the right conversations happening about patient expectations, and what happens when expectation doesn’t meet the reality of what you get, or when the desire for cosmetic surgery is merely a symptom of a larger individual problem, or when something goes wrong?
Fitness to practice
The UK falls low on the ranking of the number of cosmetic surgeries conducted worldwide. It did not make the International Society of Aesthetic Plastic Surgery (ISAPS)’s top 24 countries for cosmetic procedures (both surgical and non-surgical) in 2016, and indeed contributed less than 0.2% of the total procedures conducted globally as reported.
Despite this, there is an established and independent community dedicated to the regulation of cosmetic surgery and the protection of its patients. There are private services such as Cosmetic Surgery Counselling, advice from the NHS, and groups like the British Association of Aesthetic Plastic Surgeons (BAAPS) and the National Institute for Health and Clinical Excellence (NICE) that are active in protecting and informing prospective patients.
Part of that is ensuring that there is a system of support for patients who are not happy with their surgeries. According to the UK’s General Medical Council, it closed 16 complaints from members of the public relating to 13 individual doctors, concerning the quality of cosmetic surgery and in 2016 it closed 17 complaints relating to 14 individual doctors, concerning the quality of cosmetic surgery. These figures relate only to complaints that have been promoted to a “case” and don’t include records of complaints closed at the initial triage state of the council’s system of “fitness to practice” procedures.
Although these figures seem relatively low and there is no significant rise in complaints from 2015 to 2016, there is still a concern that patient satisfaction is not being met.
In the US, some critics claim that client satisfaction is subject to occasional manipulation so as to benefit the institution rather than the mental and physical wellbeing of the patient. In an article from last year, Medical News Today writes that “there are even anecdotal reports of doctors altering their medical judgement to improve patient satisfaction and minimize negative reviews – for example, prescribing antibiotics or strong pain medication to keep patients happy and move them quickly through the system” in US institutions of cosmetic surgeries.
Cases like this suggest that although plastic surgery is a service, it is also marketed and treated like a product. Although perhaps not as extreme, there are definite hints of that within the marketing of cosmetic surgery procedures within the UK. Perhaps one of the most well-known plastic surgery clinics in the UK is MYA. Their website features pictures of slim, beautiful women (MYA patients), a punchy hashtag (#MYAWORLD), and an invitation to “join the party” all in an effort to “Make Yourself Amazing”. Their ads are placed in between music shows on MTV Dance and MTV Base, and feature equally skinny, equally beautiful women (also MYA patients) that much reflect the actresses in the glitzy music videos displayed on those very same channels.
MYA doesn’t have a blasé attitude towards the seriousness and the implications of plastic surgery — it has a forum that allows past and prospective patients to freely talk to each other about the realities of recovery, it has guidance on the patient’s journey and aftercare, as well as a service which allows patients to have full access to a nurse hotline. But, campaigners say the consideration of that seriousness is an afterthought to the procedure, and not necessarily something that is promoted with equal weight.
This kind of criticism is not new, and nor is it specific to MYA. In 2005, the then-President of BAAPS, Adam Searle, condemned the practice of promoting plastic surgery as a product or a prize.
He has previously said that giving a surgical procedure as a prize is “an unbelievable, dangerous and highly unethical practice” and that the decision to perform any surgical procedure should be based on “common sense, case selection, good surgical decision making and patient safety. The offer of a cosmetic surgery procedure as a prize is an awful manifestation of the trivialisation of medical care in general, and aesthetic surgery in particular”.
This stance, and others like it, go hand-in-hand with the way that the cosmetic surgery community in the UK has reshaped its approach to and support of patients.
Psychotherapist Deborah Sandler founded Cosmetic Surgery Counselling Services in 2000, which provides guidance and counselling to clients at all stages of their plastic surgery journey. Sandler, too, is interested in the conversation regarding the regrets or misplaced expectations that patients have of their surgical procedures. “It is an important issue,” she tells me when I first reach out to her, “and one that is not being fairly represented …yet.”
Sandler speaks to The Overtake about the disappointment some patients may have, and the options available to them in that case.
Why do people have regrets after their surgery?
Regret often stems from disappointment. A common cause for patients to be disappointed with their results is inadequate communication at consultation. It is so important for the patient to be clear on his/her goals, and equally for the surgeon to be honest about his/her abilities and limitations.
Is it common for people to have regrets after their surgery?
How common regret is after surgery is unclear due to insufficient data but even one patient regret is one too many. A lack of data may lead the public to believe that regret is uncommon. The Royal College of Surgeons aims to improve the overall level of service by introducing their new Cosmetic Surgery Certification but patients are likely to need help to make sure they can adequately communicate to the surgeon what they want. Regret can be short or long-term depending on the amount of help and support a patient receives, which depends on the surgeon making appropriate timely referrals. Many of my clients complain that the option of referral to emotional support was not offered to them, which means that by the time they find me they may have been suffering for longer than necessary. Emotional support can provide great relief to patients.
Do you feel that the preparatory stages of cosmetic surgery – clinical appointments with their surgeons etc. – sufficiently informs patients?
Unfortunately, it is still the case that patient advisors and other marketing personnel continue to be a main source of information: they can be mistaken for surgical experts so the information is insufficiently objective. Not all surgeons are good communicators and sometimes patients are persuaded to have procedures which are inappropriate or likely to be ineffective.
How much of the onus is on the surgeon for rejecting a cosmetic surgery? Does it happen often enough?
It is difficult to know how often this happens and whether it is often enough. Screening tests have been recommended by psychologists in order to identify patients considered unsuitable for surgery but data on their use or value is very scanty. It is also not clear whether patients so identified will be referred for appropriate help and alternative treatment. Surgeons would benefit more from working with a counsellor who specialises in this field and can spend time with the patient to explore their expectations and knowledge in detail, without any commercial pressure. Currently, this option is too often not provided even though it has been recommended. Collaboration is required for the surgeon to make a well-informed decision but ultimately the onus must rest on the surgeon.
What are some of the problems that people encounter after surgery in terms of their regrets – for instance, dissatisfaction with recovery periods, expecting a better quality of life because of their surgery, or dealing with their new appearance?
There is little data available on the frequency of poor outcomes and much more systematic reporting and evaluation is needed. Much of the data available comes from NHS reconstructive operations and is not about the very different field of private cosmetic surgery. Your question mentions some of the regrets, such as having to wait up to a year for final results, but there are many more possibilities such as those resulting from unrealistic expectations of enhanced appearance and social confidence, surgical complications, need for unexpected extra expenditure on further procedures, and other possible causes of mental distress which can be very severe. In many cases, patients are simply told that they are suffering from psychological issues when they are actually suffering from a disappointing result. Cosmetic patients, like many other people, need to be given opportunities to talk about their situation and concerns, and that’s a need recognised by the charity Heads Together, launched by Prince Harry and the Duke and Duchess of Cambridge.
Are there any patterns in which kinds of patients tend to feel regret over their procedures?
It is generally recognised that patients with body dysmorphic disorder are unlikely to benefit from surgical procedures and it is important that such a disorder should be recognised by the practitioner and appropriate referral made. When clinics and surgeons learn to work alongside counsellors as a matter of routine, these and other patterns can be more easily evaluated. Typically patients suffer regret when surgeons fail to deliver on their over-optimistic promises or refuse to correct what a patient has identified as a problem in the result.
What can people do to make sure that they are ready to go under the knife?
The most important thing a patient can do in order to get ready for surgery is to speak to an emotional expert (such as a BACP counsellor like myself) in order to ensure that they have not been misled by marketing promotion but instead are being offered reliable facts and emotional support. Counsellors can help patients learn how to research surgeons and procedures, risks, complications and recovery requirements without commercial pressure.
Is there anything else you think is important to mention?
The ‘recommendations’ referred to above come from the recent Health Education England Qualification Recommendations for Non-Surgical Cosmetic Practitioners. Independent emotional support provided by counsellors helps inform patients and, where possible, ensures realistic expectations. Patients can be reassured that accepting the option of counselling does not imply that they are judged to have any type of mental health disorder.
Reconstructive or aesthetic surgeries boost self-esteem and indeed it could very well improve the patient’s quality of life and their approach to life. But what is not talked about enough, is what happens when cosmetic surgery does not increase quality of life as someone expects it to, and when someone is dissatisfied with the outcome. And that’s the conversation that we need to begin.
Tania Tavares-Pinto 11th January 2018