Abstract

Cosmetic surgery includes operations and all other invasive medical procedures where the primary aim is the change, the restoration, normalisation or improvement of the appearance, the function and wellbeing at the request of an individual. Plastic surgery trainees have to build requisite skills by seeking additional training and qualifications. The necessary training, experience and acquisition of professional standard is fundamental to starting an independent cosmetic practice.

Aim: To educate junior plastic surgeons on setting up a cosmetic surgery clinic and practice.

Settings and design: Brief expose on the requirements for a doctor intending to start a cosmetic surgery practice:- ethics, communication, documentation, care, infrastructure, management skills and the challenges to face

Conclusion:: A cordial doctor-patient relationship, empathetic handling of patients, proper counselling, proficiency in skills, and adherence to established guidelines are the best insurance against litigation

Keywords: cosmetic surgery; clinic; client.

Citation: Subin Joseph. Guidelines to starting a cosmetic surgery practice. Open J Clin Med Images. 2021; 1(1): 1007.

Introduction

Cosmetic surgery includes operations and all other invasive medical procedures where the primary aim is the change, the restoration, normalisation or improvement of the appearance, the function and wellbeing at the request of an individual [1]. During plastic surgery speciality training, trainees gain an overview of cosmetic surgery. However, they have to build it by seeking additional training and certifications.

From an ethical point of view, one must ask whether this evolution of cosmetic surgery creates more problems than it solves. Cosmetic surgery is almost always self funded and may be taxable. This can lead to financial vulnerability, and may be one of the factors associated with unrealistic expectation of positive gains after the procedures. High levels of anxiety regarding body image where appearance is within the normal range should trigger psychological evaluation.

The interdigitation of ethical issue with economic one is most clearly seen in cosmetic surgery. Consumers may regard cosmetic surgery as a commodity that is bought rather than a service provided by a trained professional and may recognize cosmetic surgeons as business people. Marketing and advertising leads to shopping. While shopping for cosmetic surgery leads to unhealthy frictions between specialities and colleagues.

Requirements for a Trainee

• Training, experience and knowledge [1]: The first and best thing one should have before starting your own independent cosmetic clinical practice is the necessary training, experience and professional standards. It adds to your confidence. Even if you don’t have the knowledge in every range of cosmetic pro cedures, at least you should have in the common procedures people are demanding. These include liposuction of male breast and abdomen, fat injections, abdominoplasty, breast reduction and augmentation, botulinum toxin injection, fillers and chemical peeling. Also, one should be thorough about the current trends in cosmetic clinical practice, patient’s demands, healthcare registration, legal requirements, staff training and the wide range of cosmetic products available in the market [2]. Anticipating emergencies during procedures and knowledge of basic resuscitation to tide over the crisis should not be forgot ten.

• Ethics [3,4]: Never forget the ethics during practice. It depends on society, cultures, traditions, political thinking and legal controls. Practice only what you learned and know. Keep in mind the quote- “first, do no harm.” Always ensure that the four criteria laid by the international society of aesthetic plastic surgery as “patient safety diamond” 2010 [5], is strictly followed. It includes.

• Procedure - Appropriate for the patient

• Patient - A good candidate for the procedure.

• Surgeon - Qualified and experienced in performing the procedure.

• Surgical setting – Safe with trained personnel and emergency procedures in place.

• Availability: All patients appreciate the physician who is readily available to them. They would definitely be impressed if one can answer their queries at odd timings or weekends (by call). If a surgeon is going to be away, he should make adequate coverage during his absence. The covering doctor should be qualified and competent.

• Good reputation and contacts: Good reputation and contacts among your colleagues, friends and family bring you patients. Satisfied patients will act as your ambassadors. Punctuality has to be maintained to build good doctor-patient relationship and impression. The surgeon should follow good bedside manners and treat his clients with respect and dignity. It is important to protect the patients’ confidentiality. Some patients do not want to discuss the matters even with family members and this should be respected.

• Infrastructure: A formal training in business and administration is not particularly essential to establish a cosmetic surgery clinic but may be an added advantage. Easy accessibility, spacious private cabins with well lighted areas, client waiting area, wash rooms, baby feeding rooms, staff to help adds to clients’ satisfaction. You should have the necessary primary requirements of a hospital including the laboratory services, pharmacy, vehicle services, drinking water and food supplies. So it would be better to have easy access to the airport.

• The clinic premises can be owned, or in a rented apartment, preferably an isolated building. If not, there should be clear and adequate signs to direct the clients. There should be facility for waste management. If a surgeon cannot afford the whole setup, a group practice may be considered. Mutual help will be fruitful in surviving and balancing financial bearings. It would be better to have a hospital affiliation to send the patients if needed in case of emergencies.

• Office Cabin: Office cabins and patient waiting rooms should be decorated decently. There should be enough chairs and potable water supplies. Television, magazines, newspa¬pers, books, brochures and information leaflets about cosmetic procedures add to client comfort. The practitioner’s degrees, certificates, awards, medals, certificates of special recognition; patient testimonials displayed on the wall adds for positive im-pression.

• Photography [2]: The clinic should be optimized for photography as best as possible, or an ideal studio may be provided. There should be a grey or medium light blue background or curtain with a good quality camera and a light source. A black background can be used to eliminate shadows if there is no light source. Always get an informed consent before taking photographs.

• Staff: Staff in the clinic reflects the physician and greatly influences the doctor-patient relationship. It includes a nurse, attendant, manager or patient coordinator and a receptionist at the minimum. All staff should be smart, well dressed, polite and compassionate to the patient. Staff should be proficient in both native and English language. There should be a provision for a translator if possible. The nurse should be experienced and should be supportive. The female nurse is valuable while examining a female patient. She can act as a witness to what is being told or done to the patient. This can save the surgeon from allegations of misconduct. Also, a nurse’s comments should not contradict that of the surgeon. The patient coordinator or manager should be a graduate and be smart enough to handle many issues and multitask. This person can screen the patient for their expectations, satisfaction and other problems related to both the clinician and the clinic. The receptionist plays a key role in attracting the patient en face and over the phone. This person should be smart enough to answer the clients promptly and should be knowledgeable about the practice and the procedures the surgeon does and does not do.

• Instrumentation [6]: Basic surgery related instruments and dressing materials should be kept ready. Good magnifying loupes, good quality light source, operating theatre table that can be tilted, and adjustable, bipolar cautery, liposuction cannulas, sterilization units should be available. Instruments can be shared or can be hired. Lasers machines can be shared with clinics or leased.

• Funding: Necessary finance can be mobilized from banks, financial institutions or cooperative credit societies. Survey all these possibilities and select the suitable funding that aid in long term benefits.

• Communication [1]: The concept of referring to a person who is seeking a cosmetic surgery as patient does not sound logical as he/she has no abnormality. People approaching the cosmetic clinic should rather be considered clients; Clients who trust us in providing them a better appearance which they are going to showcase to the world. A word of caution is hidden in this approach as any discrepancies in their expectation may not be easily tolerated by the clients. Clients may come with a variety of fairy tale expectations about cosmetic surgery. Ask for their problems in detail. Art of listening to problems makes the client comfortable in the first place. It is necessary to under¬stand the depth of clients’ thought regarding cosmetic surgery and the trigger behind the client’s time consuming visit to the clinic. Next thought in our mind should be whether that trigger¬ing reason can be addressed or not. A realistic picture of achiev¬able targets must be communicated after sieving out the fairy tale expectations. We need to explain the appropriate available options for their problems along with the cost of each and their benefits, just like salesperson treats their customers. We should be transparent in explaining to them the procedure, its limita¬tions, possible complications [6], outcome, follow up visits, af¬ter care and second sittings including their financial bearings. Adequate time should be given for the client to think. Doctor’s advice and client’s demands have to be weighed to arrive at a final conclusion. Give them the option of no treatment along with the medical and non medical alternatives. It should be made sure that we have understood the requirements of the client and the client has understood the procedure. The quint¬essential aspect of running a safe cosmetic surgery practice in this present scenario of litigation against doctors is communica¬tion. Video counselling of this communication is safer now-a-days and it can act as high-level evidence in case of litigations. All these can be conveying our professional qualifications and experience in the field of cosmetic surgery, giving contact num¬bers to resolve their queries will add to the trust. While deal¬ing with the angry patients, surgeons should not lose their cool. One should try to explain to them in detail the complications and the ways to correct it. Make sure that angry clients are ad¬dressed privately and not in front of other patients. Try to re¬duce or wave off the financial bearings in such cases.

• Patience for patients: First and foremost, listen to your clients (patients). Deal with one patient at a time. Always respect and keep absolute privacy for clients in every act. Procedures have to be planned on a separate day or timings. Never be in a hurry to do the procedure on the same day. Offer them a period of one or two weeks to think and decide.

Clients should be asked for their medical history, other diseases, past and ongoing medications, previous surgeries including cosmetic procedures. Personal habits like diet, eating disorder, exercise, smoking habit, sleep, all should be enquired. Probe for doctor shopping attitude and make sure that clients are emotionally stable by psychological assessment, if needed.

New patients coming without appointments should also be given a word before sending them, if you are not completely available for an elaborate discussion. For that, procedure rooms and patient visiting rooms should be made adjacent to each other or should have an assistant with necessary knowledge in communicating the situation.

Following procedures, clients should be able to contact you for any further procedure, related assistance or unexpected complications and you should be available to address that. Complaints following procedures should also be given due importance and should be managed with utmost care. Junior surgeons can seek help from seniors or cosmetic society groups. Don’t hesitate to involve them, if needed.

• Consent forms: At least, select the right clients with a well written informed consent in the presence of a witness and leave the unsuitable ones. Consent should include the relevant medical history, co-morbidities, procedure and the alternatives, benefits, risks and side effects associated with procedures, post procedure care, patient responsibilities, how long the effects of the procedure are likely to last, duration of treatment, re-operations and multiple sittings including their monetary needs should be well recorded. Patients with specific eating disorder, lifestyle habits and medications should be recorded.

“Downtime” associated with every cosmetic procedure should also be informed. Photography consent forms should include the following five purposes

(1) For filing in surgeons records,

(2) For educational purposes,

(3) For publishing in literature and meetings,

(4) For informing and educating other potential patients through consultations and websites,

(5) For medicolegal reasons.

• Fees: Inform the clients regarding the cost of each procedure well in advance at the initial consultation. It includes the cost of each procedure, after care charges, second sitting charges and even the cost associated with unexpected complications and emergencies.

• Secure and showcase yourself: You should have a security or protection against a loss or other financial burden before starting the setup. You should give enough time and money to advertise and promote yourself including one’s training, fellowships, degrees and the available options among your colleagues, friends and clients. This includes using the social media like newspapers, WhatsApp, Facebook, Twitter, Youtube, health and other magazines. One can start his/her own website. Most of the clients are consulting because of the information on the website. It should specially include the aesthetic training and fellowships and should not make false claims. One can also portray the pre and postoperative pictures of patients without revealing the identity in the website after getting their consent. All these should be under ethical considerations, honest and within the specialist’s experience. One should obtain a professional association membership. This will help in clarifying doubts, information assimilation and acts as a support during difficult times.

• Documentation: All visits and discussions, final conclusions, procedures, risks and complications, after care, multiple sittings and costs should be well documented. Efforts should be made to computerize medical records for quick retrieval. It helps in future reference and also in dealing with the litigations. The surgeon should follow the national medical council regulations and guidelines for keeping medical records. According to that, maintain in-patients’ records in a standard proforma for the specified period from commencement of treatment. Medico-legal case records should be maintained until the final disposal of the case even though only a complaint or notice is received. Request for medical records by patient or authorized attendant should be acknowledged and documents issued within the specified period. Also maintain a register of certificates with the full details of medical certificates issued with at least one identification mark of the patient and his or her signature.

• Managerial skills: Along with surgical skills, the surgeon should achieve necessary managerial skills too. The surgeon should be able to work in teams with clinical and non-clinical staff. The surgeon should make everybody to work constructively to provide a safe environment for his clients and this helps in the upliftment of the clinic.

Challenges

• Lack of awareness among health care professionals and public

• Worry about another surgery, hospitalization and side effects.

• Financial constraints

• Inadequate counselling regarding options of breast reconstruction during mastectomy.

• The thought of cancer vs cosmesis.

• Taboos, stigmatisation and shyness.

• Less number of cosmetic centers in private sector.

• Scarcity of facility in public sector

Patient care

• Before procedure: Always make sure that the patients are healthy and are fit to undergo the planned procedure. Doctors don’t agree to carry out a procedure, if there is a significant risk that would have a detrimental effect on patient’s health. For female patients asking for genital procedures, always ask for a gynaecological evaluation prior to the procedures. Patients should be ready to change the dietary habits and smoking, follow the after care, assess whether they have understood the procedure and its benefits, risks and complications and have realistic expectations.

• During the procedure: Re-check the consent forms before beginning the procedure. Make sure that anaesthetist, staff, required equipment and recovery units are ready. Resuscitation equipment and drugs have to be kept ready, if any emergency happens.

• After the procedure: The patients should be well monitored following any procedures. Facilities and length of recovery will vary according to the level of invasiveness of procedures. The doctor should be ready to provide care or necessary arrangements even at odd times following procedures. All procedures should be followed by advice regarding care, follow up visits, emergency services, lifestyle changes, cessation of smoking and follow up or revision procedures, if required.

Conclusion

John Owsley, an American plastic surgeon wrote, “The only currently acceptable source of advertising for the physicians is their pleased patients [7]. Surgeon’s approach should change from “patient” to “client” attitude. The surgeon should be able, available and amiable. You should follow-up your patients for assessing your ability, aesthetic judgment, to improve the confidence and learning. A cordial doctor-patient relationship, empathetic handling of patients, proper counselling, proficiency in skills, and adherence to established guidelines are the best insurance against litigation.

References

1. Professional Standards for Cosmetic Practice (RCSENG - Professional Standards and Regulations 2013).
2. Agrawal K, Bhattacharya S. Textbook of Plastic, Reconstructive and Aesthetic surgery- Principles and Advances in Plastic Surgery; Vol Two. 1st ed. Delhi: Thieme Publishing; 2017.
3. Gupta S. Ethical and legal issues in aesthetic surgery. Indian J Plast Surg. 2012; 45.
4. Murray JE. On ethics and the training of the plastic surgeon. Plast Reconstr Surg. 1978;61.
5. Foad Nahai. (2010, December 03). ISAPS Global summit on patient safety in cosmetic medicine and surgery. ISAPS NEWS, volume 4(3), 11. https://www.isaps.org.
6. Murray JE. Evolution and philosophy of plastic surgery. In: Achauer BM, Eriikson E, Guyron B et al. editors. Plastic Surgery: Indications, Operations, Outcomes. vol. 1. St. Louis: Mosby; 2000.
7. Owsley JQ. Editorials: Some current trends in the ethics of medical practice. Plast Reconstr Surg. 1975; 56.