Features
Competence vs qualifications
Should a general practitioner with a special interest in aesthetic medicine be allowed to perform complex surgical procedures like liposuction? A panel of mixed disciplines discuss the issue
Mr Dai Davies, consultant plastic surgeon, London
We have seen a few cases in the news about patients who have died following liposuction procedures—one, in particular, was carried out by a GP. The establishment’s response was to improve the training for people undertaking cosmetic surgery procedures. An interface specialty group was set up comprising plastic surgeons, ENT surgeons, eye surgeons, oncoplastic breast surgeons and dermatologists—but not GPs. This is funded directly by the Department of Health. Participants are given three months’ training in cosmetic surgery.
I am concerned for the patients. They should understand what is going to be done to them by whom. After I had finished surgery recently, a surgeon arrived to take over the theatre. It transpired that he was, in fact, a GP carrying out high definition Vaser liposuction. He hadn’t organised an anaesthetist so mine took over. He spent five hours performing this liposuction and took seven litres of fat away from the patient.
In my book, this is dangerous. America has seen deaths resulting from liposuction, usually during office procedures where large volumes of fat are removed.
Dr Rupert Gabriel, GP, WIltshire
I work as a GP with a surgical interest, or GPSI. I carry out procedures such as carpal tunnel surgery, vasectomies and removal of skin cancers. There has been a frame shift out of the hospitals into appropriate general practice. But my procedures are carried out in an operating theatre with all the appropriate facilities and is appropriately staffed. I do not perform treatments under general anaesthetic or sedation.
Some consultant hand surgeons accepted that GPs can perform carpal tunnel surgery; others did not. But times are changing. Techniques are more refined. Some of these treatments can be appropriately carried within a general practice setting. Over the past decade, the quality and standard of our audit figures and outcomes have even exceeded what our hospital-based colleagues can achieve.
The example you mentioned is particularly extreme—seven litres of fat under anaesthetic is not what I or many of my other GP aesthetic physician colleagues do.
We’re doing a very limited, safe, well-researched procedure backed up by scientific evidence with good outcomes in addition to our other non-surgical treatments. But I will refer, if necessary, to our surgical colleagues. If I see an uncomplicated carpal tunnel syndrome, I will operate. If I see an elderly patient with recurrent disease and problems, I refer to my hand surgeon. It’s a matter of degree.
Mr Dai Davies
Mr Al-Ayoubi, as an ENT surgeon, where does the ENT spectrum fit into this? I understand you carry out breast uplifts—this is a bit of a stray from ENT?
Mr Ayham Al-Ayoubi, ENT and facial plastic surgeon, London
Whatever our surgical or medical background, we start out doing what we were trained to do. I trained in ENT through an intensive programme at the Royal College of Surgeons of England. Halfway through this, I started to do facial plastic surgery.
I have always had an interest in lasers, so from lasers for middle ear surgery and throat cancer, I moved to SmartLipo. The technology is laser lipolysis. I treated more than 500 patients in two years on the chin and small areas with good results. I moved on to larger areas, and then laser-assisted liposuction. I tighten the skin, laser the fat and suck it out. But I never went beyond two litres of fat in one session.
During this period, laser technology evolved from small machines with limited energy to those that give much more energy. Radiofrequency evolved and BodyTite came on the scene and now what we are doing is proper liposuction.
Who should do this procedure? An ENT surgeon who has never performed traditional liposuction after adequate training? There is no training available from a proper academic establishment. This is a very grey area. Training is the crucial point. It’s not about qualifications.
The cosmetic surgery industry is evolving haphazardly. It is not structured.
Professor Marco Gasparotti, consultant plastic surgeon, Italy
I know general practitioners, ENT surgeons and gynaecologists—ophthalmologists are doing breast augmentation, dentists are doing rhinoplasty and facial procedures. Each of us should stick to his own profession. If the law allows surgeons to do everything except radiology and anaesthesiology, we cannot stop this.
I would suggest focusing on the right teachers for cosmetic surgery training courses; otherwise, we will have confusion in the field with bad results and bad publicity. Physicians need to be well trained and the procedures carried out using good technology, an anaesthesiologist and good safety.
Mr Bryan Mayou, consultant plastic surgeon, London
We [consultant plastic surgeons] have had huge, lengthy training. We had exams, and accompanying senior practitioners every day taught us so much. It was a successful way of doing things. Training is much shorter now. We tend to think it will be evident to patients that trained practitioners are going to be better than those who are not.
Nowadays, if you have the right website, you will get the patients, no matter what your qualifications are. Patients aren’t discriminating enough, so we still have to show that we do things better.
As for GPs carrying out procedures, they must have appropriate training. They have to know the field they’re operating in. They need to have colleagues around to consult with. They need to have good anaesthetists, a proper hospital and all the accoutrements of surgery.
A GP cosmetic surgeon is unlikely to have all of that. I’m sure there are extremely gifted GP surgeons who have not had any surgical training other than minimal training for that particular technique.
While I’m sure they’re very good at what they do, they will be few and far between. It will be harder for them to have high standards and they’re not going to know their limits.
Dr Gabriel says that he knows his limits and when to refer, but in practice many don’t.
Mr Dai Davies
As a GP, do you pay excess on your medical defence union?
Dr Rupert Gabriel
I have a separate insurance with another company. I’d like to point out that if insurers were having huge lawsuits for every procedure we did, they’d quickly increase policy costs to beyond our reach or to refuse to insure altogether.
They research procedures that they cover. If you look at the way they look at the market, it shows there are a reasonable number of non-surgical operators doing procedures in a safe and reliable manner.
Mr Bryan Mayou
But over the years, we’ve seen disaster after disaster from the same surgeons. Somehow they’re very thick-skinned and keep going.
Dr Rupert Gabriel
Patient selection is critical. The patients you would select to treat, I would select to refer. In terms of results, do you look forward to seeing your reviews or do you dread them?
If you look forward to your reviews because you can confidently expect good results in the vast majority, then that is a telling thing.
Mr Dai Davies
We’re all registered with the GMC but anyone in this country can call themselves anything they like. There is no attachment to the words “cosmetic, surgeon or plastic surgeon”.
Mr Hugh Henderson, plastic surgeon, commenting from the floor
Unless plastic surgeons or the group involved in regulation are willing to forgo a significant portion of their income to get regulation, we won’t have it and the system will remain chaotic. There are too many people who see an easy way of making a quick buck. The problem is ignorance. Practitioners don’t know what they don’t know and therein lies the danger.
Even after reasonable training, practitioners continue to make mistakes. They are cavalier. The best practitioners to perform an operation are those who are humble and know you can make mistakes. They are willing to discuss it beforehand and are prepared to see patients more than once.
I’m a great believer in two consultations. From just one consultation, the practitioner gives the patient the impression the procedure is easy and there is not much to discuss. The patient will then go away thinking: “It must be a very simple operation or I would need to talk more about it.” There are many intrinsic dangers, not only in surgery but also in the preparation, the consultation process. This is totally unregulated.
Mr Bassim Matti, plastic surgeon consultant, commenting from the floor
As a doctor, you have to be ethical. If you are just doing the job for the sake of money, you will fail. If you are training and you know you won’t help the patients, you will have a problem with yourself because you have a conscience. If you don’t have a conscience, then it’s up to you and your abilities.
Mr Ayham Al-Ayoubi
We need to look at the wider picture. As a surgeon—with no exception in any surgical field—you go through your training and then reach a turning point. You gain experience in whatever you are doing, whether you are a gynaecologist, ENT surgeon, maxillary facial surgeon, and you adopt the necessary skills.
Take, for example, a tonsillectomy. I have done thousands of traditional tonsillectomies. You then start to do bipolar, followed by laser tonsillectomy. Is one way any better than another?
A huge audit was carried out through the Royal College of Surgeons of England and the British Association of Otolaryngologists, which concluded that the best and safest tonsillectomy method for our ENT patients is the classic dissection technique—bipolar has a very high risk of secondary bleeding.
Now, there are hundreds of ENT surgery consultants in the UK who carry out only bipolar tonsillectomies. They have a very low rate of secondary bleeding. Their argument is, “I am doing a good job, why should I suddenly change to laser tonsillectomy with all the problems of lasers?”
Cosmetic GPs entering this field, ENT surgeons like myself, ophthalmologists and gynaecologists are not doing traditional liposuction. At my own clinic, we have three operating theatres with all the facilities for treatments from Botox injections to aesthetic plastic surgery.
A plastic surgeon has done hundreds of traditional liposuction procedures. Why should he bother about sticking a laser under the skin or using a radiofrequency machine?
In America, many plastic surgeons are doing laser-assisted liposuction. While they all trained as plastic surgeons, they took it one step further and embraced the technology.
Mr Dai Davies
What about the responsibility of the companies selling their machines through high-powered marketing?
Mr Bryan Mayou
We supply machines to surgeons and qualified practitioners. When we brought SmartLipo to the UK, we marketed the machine, showing that all it would do is take small areas of spot fat away that diet and exercise could not. Now, doctors are adventurous by nature and many wanted to turn themselves into plastic surgeons overnight. I can’t do anything about that, but the marketing we did for the machine was fair, honest and we, as a company, never deviated.
Dr Rupert Gabriel
I have run minor surgery courses for GPs at Bath University for over a decade. We go through all the techniques. We practice on models and observe technique but I say to them at the end, “This doesn’t qualify you to operate on someone. You need to do supervised cases, keep a log book and be signed off when you’re competent for each specific procedure.”
Professor Marco Gasparotti
In reality, patients come to me and ask, “Can I have a lunchtime liposuction?” What is a lunchtime liposuction? If you go on the internet or read magazines, lunchtime liposuction is a €1000 liposuction procedure done in the office in half an hour. This is the problem. If everybody advertised that liposuction is a lunchtime procedure at €1000 and they come to us and it’s €12,000, they will go for the former. This causes much confusion among patients and harms plastic surgery.
Mr Shailesh Vadodaria, consultant plastic surgeon, London
There are four factors for anyone providing body sculpting procedures. First is to know the equipment we use, whether it is traditional suction lipolysis or a machine. Second is the aesthetic eye, beyond the science and medicine. The third is medical and surgical knowledge about performing the procedure, and last, how to identify and manage major complications such as fat embolism, intraperitoneal rupture and intrathoracic rupture.
Mel Braham, chairman, Harley Medical Group, commenting from the floor
In terms of people doing plastic surgery, a law was introduced in 2002 in the UK that says that unless you have been registered as a plastic surgeon, you’re not allowed to carry out cosmetic surgery. It’s obviously not being implemented.
It comprises a report of the chief medical officer. It clearly states that if you performed any plastic surgery before 2002, you will be grandfathered. You have to be registered with the CQC [Care Quality Commission], maintain expertise and continue within your level of competence.
It also clearly states that there are around 65 GPs who were performing cosmetic surgery before that date who will be allowed to continue.
Audience comment
We have liposuction as performed by plastic surgeons and liposuction as performed by Dr Gabriel. I think they’re different.
Dr Jeffrey Klein, a dermatologist, popularised microcannular liposuction at a time when plastic surgeons were performing under general anaesthetic without any tumescence. He revolutionised liposuction in the United States, moving it from hospitals to an office setting. He is one of the great exponents of the type of liposuction that Dr Gabriel is doing.
As far as I’m aware, there have been no deaths from small cannula liposuction performed under local anaesthetic. It’s a very safe procedure involving small amounts of fat—localised deposits which will not shift with exercise or diet.
Mr Dai Davies
A study was carried out by the American Society of Plastic Surgery about the major mortality and morbidity for liposuction. The commonest causes of death were fat embolism, intraperitoneal/intrathoracic internal injury and infection while the cannulas were being restabilised and they were not being disposed of. These occurrences were in small clinics.
Audience comment
We’re forgetting one very basic thing: why are the patients coming to us? They’re coming for an aesthetic result. While death is obviously the extreme, much can go wrong, including loose skin irregularity. There is often a lack of technical competence and poor patient selection leading to poor results, which are probably more relevant.
Mr Taimur Shoaib, plastic surgeon, from the floor
It was reported in the media recently that someone was sent to prison in the US following an office-based death after liposuction. Consensus of opinion was that lidocaine toxicity caused the death.
Mr Dai Davies
If there is to be any control in the industry, it’s got to be by law and the government have to take it seriously. Otherwise these instances will just increase.
Mr Hugh Henderson, plastic surgeon, from the floor
Until there is regulation, we won’t get anywhere. Now we also have a total deregulation of lasers which, to me, is an indication at government level that they don’t give a damn.
Audience comment
We are behind in the UK. Since June 2011 in France, it is forbidden for any doctor or surgeon to perform traditional laser lipolysis or cryolipo, or any technique that involves fracturing the fat.
The media took the approach that liposuction is bad surgery, that it’s catastrophic—instead, we should do this magical daytime or lunch hour procedure. This has officially died in France and is dying in the UK.
But appropriate indication and patient selection are important. We must all have an ethical approach to our patients.
The government has found there is no point in regulating laser hair removal or vascular lasers. But only proper establishments are registered with the Care Quality Commission. So we’ll soon see that the traditional liposuction is coming back into favour. On the other hand, many forms of technology-assisted liposuctions are taking place.
But we’re going through great upheaval with revalidation and appraisal. Structures are now in place where concerns can be brought forward. The debate should not be so much about operating outside your sphere of expertise but about being competent as a surgeon.
Mr Dai Davies
It comes back to the level of expertise that you can give to your patient. I’m quite happy to say that if you are doing hundreds of Vaser liposuctions, you will be better at it than me because I don’t do any.
