ESPRAS Position Paper on Patient Protection in Plastic, Reconstructive and Aesthetic Surgery

Preamble

The European Society for Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) is the overarching organization for Plastic Surgery which pursues the interests of all the affiliated national societies for plastic surgery throughout Europe. ESPRAS is dedicated to providing patients with the best possible treatment by highly trained and skilled board-certified Plastic Surgeons in all the subspecialty areas of Plastic Surgery, including reconstructive, aesthetic, hand and burns surgery.

Problem

Numerous medical disciplines and specialties exist, each entailing regulated, detailed and regularly updated training curricula. After completing a medical degree, medical doctors perform a multiple-year residency to specialize and focus their education on a specific area of medicine. This professional focus improves the efficiency and quality of care provision. Certain procedures, diagnostic and therapeutic, can therefore only be performed by adequately trained and specialized physicians and surgeons. Board-certification in Plastic Surgery requires a five- to eight- year training by an accredited plastic surgical institution, including reconstructive, aesthetic, hand and burn surgery. However, in many countries, terms like “Aesthetic Surgeon”, “Cosmetic Doctor” or “Beauty Surgeon” and others are pseudo-legitimized by non-authorized commercial organizations which have no legal basis and no clear regulation.

Aesthetic Surgery is financially attractive for many and in addition to appropriate specialist surgeons also attracts non-surgical specialists, medical doctors and paramedics who in turn perform a wide range of surgical and non-surgical aesthetic procedures without appropriate training. Many aesthetic procedures are therefore performed by practitioners with a limited skill set, covering limited indications, and with a lack of awareness of possible complications and their management.

Complications are an inherent concern related to any surgical or non surgical procedure or medical treatment, regulated specialized training significantly reduces the risk. However patients are often ignorant of the inadequate qualifications of doctor offering an aesthetic procedure as a consequence of a lack of transparency and provision of very selected and dubious information.

Some countries like Germany and Belgium tried to address this lack of transparency by expanding their specialist title from “board-certified Plastic Surgeon” to “board-certified Plastic, Reconstructive and Aesthetic Surgeon” and are the only specialists to include the term Aesthetic Surgery within their specialist title. While this is a first step to improve patient awareness, it does not regulate Aesthetic Surgery by law.

Aim

ESPRAS aims to protect patients from being treated by underqualified practitioners portraying themselves as plastic and aesthetic surgeons and to increase public awareness of the current lack of regulation of Aesthetic Surgery. It is intended to improve patient safety by preventing undesirable, negative outcomes or even life-threating complications. Furthermore, national governments and legislation will be supported in providing clear and transparent regulations. Some countries such as Belgium [1] already have a law categorizing non-surgical and surgical procedures, defining groups and qualifications of stakeholders in Aesthetic Surgery and also imposing sanctions when these are disregarded.

Relevance of Continuing Education

Board-certified Plastic Surgeon

The board-certified Plastic Surgeon usually completes a 5 to 6-year well-regulated training program in all regions of the body and all subspecialties of Plastic Surgery including Aesthetic Surgery, Reconstructive Surgery, Burn Surgery and Hand Surgery [2]. Providing evidence of an individual’s experience in performed surgical procedures including those in Aesthetic Surgery is mandatory. Continuing education usually includes a 6-month training in an intensive care unit and in emergency medicine. Board certification is usually achieved by passing a final exam.

In summary the following 4 components ensure training and promote patient safety:

1. Multi-year training regulated by a national board

2. Evidence of individually performed operative procedures in the field

3. Continuing education in intensive care for at least 6 months

4. Final exam

Specialist Surgeons in other disciplines (ENT, Ophthalmology, Maxillo-Facial Surgery etc.)

Surgeons of other surgical specialties are usually trained in surgical procedures limited to their anatomical area of practice but for most this does not include regulated training in Aesthetic Surgery. For board-certification, there is no requirement to perform any Aesthetic surgical procedures and there is no final exam testing Aesthetic Surgery knowledge and clinical competence [Fig. 1].

Fig. 1 Training Curriculum and qualification of stakeholders in Aesthetic Surgery.

However colleagues in surgical specialties other than Plastic Surgery can be trained to perform aesthetic procedures related to their anatomical area of practice and ESPRAS recognizes that surgeons of these specialties may on occasion have a higher level of expertise than board-certified Plastic Surgeons ([Fig. 2]) However in contrast to colleagues in anatomically based specialties, Plastic Surgeons are uniquely qualified in their ability to perform aesthetic procedures in all parts of the body.

Fig. 2 Regions of the body where specialists are qualified with a multiannual training together with a final exam.

Medical doctors without specialization

Medical doctors without surgical specialization do not complete a multiple-year regulated training program in any surgical field. They have no recognised training in Plastic Surgery, Aesthetic Surgery, or surgical intensive care, provide no proof of having performed certain amounts of surgical procedures and do not pass a final exam of a national board. Mostly basic knowledge is acquired in weekend courses or short term attachments to Plastic Surgery Departments. Medical doctors without specialization can, however, call themselves “Aesthetic Surgeons” or “Beauty Surgeons” and are sometimes pseudo-legitimized by non-authorized private commercial organizations like “beauty-academies”.

Paramedics

Paramedics do not have a medical degree, have no surgical training and do not meet any of the requirements to become a board-certified Plastic Surgeon. Most basic knowledge is acquired in weekend courses or short term attachments to Plastic Surgery Departments. Although lacking any specialist training, they might be able to call themselves “Aesthetic Surgeons” or “Beauty Surgeons”.

Patient Advice

ESPRAS as the overarching European society for Plastic Surgery emphasizes on behalf of member societies the relevance of adequate training in Plastic Surgery for patient safety. ESPRAS strongly recommends that patients clarify the true qualification of practitioners performing Aesthetic Surgery before undergoing an aesthetic procedure.

Board certified Plastic Surgeons are the only group of medical doctors who meet the highest degree of qualification, are trained in all parts of the body and in the management of complications.

Other surgical disciplines can meet the requirements to perform aesthetic procedures for the specific region of the body defined by their specialization, but not for other regions of the body.

Surgeons of surgical disciplines that include no training in aesthetic procedures during specialization, medical doctors without any specialization at all and paramedics do not have adequate training to perform Aesthetic Surgery.

Commitment

The European Society for Plastic, Reconstructive and Aesthetic Surgery is committed to continuously increasing patient safety in Aesthetic Surgery by:

• making patient safety the first priority and certainly taking precedence over personal financial interests

• steadily increasing the quality of continuing education through the national societies

• promoting academic structures especially in university hospitals to provide more scientific evidence in Aesthetic Surgery

• increasing public awareness regarding the qualifications of board-certified Plastic Surgeons

• supporting national legislation to provide clear regulation of Aesthetic Surgery to protect patients

• References

• 1 http://www.ejustice.just.fgov.be/cgi_loi/change_lg.pl?language=nl&la=N&cn=2013052321&table_name=wet Stand: 02.06.2022
• 2 Moellhoff N, Arnez T, Athanasopoulos E et al. ESPRAS Survey on Continuing Education in Plastic, Reconstructive and Aesthetic Surgery in Europe. Handchir Mikrochir Plast Chir 2022; 54: 365–373

Publication History

Article published online:
09 August 2022