The Review of the Regulation of Cosmetic Interventions led by Sir Bruce Keogh and an expert panel was published by the Department of Health on the 24th April 2013. Cosmeticsurgerycounselling.com together with Cosmeticsupport.com support this Review and note the central position of the emotional and psychological welfare of the cosmetic surgery consumer/patient. Cosmeticsupport.com is a partner of the APPG on body confidence, offering a non- profit voluntary and independent professional emotional support, psychology and counselling service specializing in cosmetic surgery patients and body dysmorphic disorder patients since Jan 2000. https://www.gov.uk/government/news/recommendations- to-protect- people- who-choose-cosmetic-surgery

As a consumer/patient and psychotherapist with a specialist interest in body image issues and cosmetic surgery counselling, I have been very concerned about the trivialization of cosmetic surgery and how this affects patients’ expectations. Regulation will offer greater physical and mental protection by reducing some of the greater anxieties suffered by patients.

The review addresses two main areas: 

1. Physical protection 
2. Emotional welfare

Physical Protection

It is easy to see from a selection of the recommendations below how much more protection will be afforded to patients who have been vulnerable in an unregulated industry:

1. A register for all medical devices including breast implants
2. Surgeons must be on the GMC Specialist Register and practicing in that field
3. Fly-in/Fly-out surgeons subject to UK standards
4. Patients can review meaningful data
5. Legislation to classify fillers/botox as prescription only 
6. Ban on incentive/special offers
7. Patients must see the surgeon and not a sales person 
8. Fund to help patients when companies go bust
9. Ombudsman for private health (including cosmetic surgery) 
10. Compulsory insurance

Emotional Welfare

The Keogh Review acknowledges the vulnerability of patients. Every elective beauty enhancement surgery contains a vast emotional component. Psychological questionnaires may create better-informed surgeons but, with the best of intentions, do not create well-informed, integrated (mind/body) patients.

It is easy to think that counsellors should only be involved when cosmetic surgery goes wrong or if a surgeon believes a patient to be unsuitable for surgery. This dated concept of counselling creates a lost opportunity to increase patient safety and negate surgical risks. Specifically trained cosmetic surgery counsellors would make a valuable addition to the forthcoming patient safety regulations resulting from the Keogh Review.

The counselling conversation is a unique experience where patients can feel safe enough to explore their issues. This is not the same as talking to a friend, although the best counselling sessions will feel that way.

Counselling (as part of the consent process) pre-operatively creates a preventative measure against rogue traders in the industry. A cool-off period is more productive when patients are referred to counsellors who understand what constitutes a well-informed patient according to new regulation.

Mind and body in cosmetic surgery have become alienated from one another and must be re-united if safety is to remain centre stage. The person-centred relationship built up in pre- and post-operative counselling becomes the intermediary between beauty shopping and medical procedures. Patients benefit from the opportunity to safely reintegrate internal (mind) and external (body) aspects of their needs. This delivers a more relaxed, realistically-grounded patient to the surgeon.

Every fibre of my being believes that counselling should be an integral part of the consent process: even more so in the cases of patients who wish to keep their surgery secret. At the very least patient support sites and support groups would benefit from the professional skills a cosmetic surgery counsellor brings to the experience. 

The quest for beauty is equally a quest for health, happiness and well-being. As consumers/patients, the false belief has been that the path to beauty, health and well-being is always safe and pretty. Regulation from the Keogh Review will go a longer way toward making this a reality if the path to well-being is clearly integrated.

The disjunction between pressurizing commercial interests of the surgery industry and the self-critical anxieties of credulous patients is where insight through counselling creates well-informed patients.

Patients who once were insecure about their looks as well as ill-informed about their choices can take pride in joining a cultural shift towards better knowledge and better outcomes both practically and emotionally.

Consultations with a surgeon are a time to concentrate on what can and cannot be done through surgery. It is not the time or the place to discuss personal psychological issues.

Consultations can create confusion in patients. Many patients may need more than one consultation with a surgeon. We are not easily able to look objectively at our bodies the way a surgeon can. Often, we are unable to picture how the discussed changes will really look. Some surgeons offer 3-D imaging but even with that it is not always easy to imagine the predicted reality. Additionally, we may think we need one thing and a surgeon may suggest something else. Sometimes we may need more than one surgery to achieve our goals. Patients may feel anxious about asking for a second consultation.

Patients need time and freedom from pressure to consider everything after a consultation. Patients may say they do not need counselling but experience shows that they spend countless hours online searching for support groups to talk about their needs and experience. Whilst these online relationships are helpful for patients, they often compound mis-information and cannot replace the benefit of conversation with someone suitably qualified to understand the sensitive issues involved. This need to talk has been exploited by sharp operators online who take referral fees or have other exploitative agendas that they keep concealed. Genuine, non-exploitative counselling sessions online through specifically tailored support groups keep patients safe in many ways.

Physical patient safety will benefit from the Keogh review. A specifically trained independent cosmetic surgery counsellor will help a patient shield themselves against the twin arrows of hype and dismissal. A safe conversation has no exploitative agenda. A more frivolous conversation about beauty and fashion can be helpful to while away the hours before and after surgery but will not enhance patient safety.  Where advertising in medical procedures exists, so too remains the need for demystification. 

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THE NEED FOR COUNSELLING
submitted by Deborah Sandler
In response to your Call for Evidence re Cosmetic Surgery I propose the following recommendations:

1. Pre- and post-operative counselling should be strongly recommended as a necessary component of cosmetic surgery.
   
2. Counsellors should be specially trained and approved.
   

Why?
As noted by Sir Liam Donaldson in 20051, there is a lack of balanced information about the risks and benefits of cosmetic surgery. Prospective patients can too often be the victims of unscrupulous clinics which offer pressurizing sales promotion. Sometimes this is even disguised as ‘counselling’ or ‘patient support’. Such practices provide a misleading sense of reassurance to vulnerable people subject to manipulative advertising.
Patients need opportunities to talk about their motivation, expectation and fears with unbiased and trained counsellors wholly independent of commercial pressures.
Who benefits?
The PIP scandal has prompted the formation of many new patient support groups with a focus on justice for patients adversely affected.
PIP patients will benefit from counselling which offers an opportunity to recover from the mental trauma caused. Many lives have been turned upside down and many are still struggling with the damaging consequences of their experience.
All patients benefit from counselling before and after life-changing and irreversible surgery.
‘Cooling-off’ periods that include counselling sessions are more productive ‘Cooling-off’ periods allow patients to consider their choice of surgeon Surgeons benefit by having calmer, more relaxed, better-informed patients Patients will have access to counsellors as advocates where necessary
Counsellors can organize patient meetings with permission. This encourages realistic expectations. Promotional static photos shown during information-

laden consultations are inadequate

Online patient support groups reveal high levels of confusion and anxiety through misleading adverting, causing poor decisions on the part of the patient. Specially trained cosmetic surgery counsellors kept up-to-date with current policies will help clarify the information patients need.
After-hours online counselling reduces post-operative stress, helping recovery. Patients feel safer knowing there is unbiased emotional support and information a few clicks away.
Current Obstacles
Creating well-informed patients requires collaboration from all parties involved in cosmetic surgery, especially surgeons and nurses The support of BAAPS and BAPRAS, both as organizations and as individual surgeons, would enhance emotional patient safety. Disappointingly, I have repeatedly been met with reluctance on their part when seeking support for this additional safety net, despite their claim to ‘tirelessly educate the public’2. I have asked BAAPS’ permission to allow me to reproduce their surgical information fact sheets on my website only to be met with ‘our surgeons are sensitive about who uses their information’ and ‘if you use our information sheets, everyone else will want to’ and ‘if you reprint this information, it is plagiarism’. This kind of information protection puts the safety and education of patients at risk.
My experience has shown that a patient who claims to have done some ‘research’ on their plastic surgery procedure will be able to talk about prices and distances and whether or not the plastic surgery clinic they are going to will drive them home. Crucially, most of their research will revolve around the photos they have of the clinic and the glossy pictures of the results that clinic is showing. Patients also generally know about a clinic’s ‘special offers’. In other words, the patients ‘research’ is often little more than reading an advertising brochure.
I understand that the current call for the ban on advertising cosmetic surgery may stop this type of ‘patient research’ but there will still be a need for patient education, information and support, even without the advertising.
Conclusions
Clear information and psychological support creates well-informed patients who are able to:
Understand their motivations physically and emotionally Manage their expectations

Make informed decisions
Know how to access psychological support pre- and post-surgically Know how to access emotional support after hours and at weekends Understand the difference between advertising and information
Not succumb to pressurized sales techniques.
Declaration of Interest
I have a training in psychotherapy and a specialist interest in body image, with personal experience of both good and bad cosmetic surgery, as well as body dysmorphic disorder. I am a member of the All Party Parliamentary Steering Group for Body Image. I have run a voluntary, independent and non-profit cosmetic surgery patient website for 13 years (Cosmeticsupport.com) offering information and psychological support, including moderated discussion forums and videos. The latter cover such questions as:
How Do I Become a Well-Informed Patient?
What Makes A Good Consultation?
What Are Realistic Expectations from Cosmetic Surgery? Will I Need Further Surgery?
The site covers all surgeries and other cosmetic procedures and receives no commercial funding. I would welcome the opportunity to work with BAAPS/ BAPRAS more closely in offering this type of information to all cosmetic surgery patients.
References:
1. www.guardian.co.uk/technology/2005/dec/22/news.medicineandhealth
2. www.baaps.org.uk/about-us/press-releases/1029-surgeons-put-forward-regulation proposal

The case against Nip ‘n’ Tuck 

Nip’n’Tuck was such a catchy slogan that it became synonymous with any type of cosmetic surgery.  There was even an American television series with that name.  The TV  surgeons were handsome. Their patients idolized them. The drama itself was mostly confined to the personal lives of the surgeons as opposed to surgical side of plastic surgery.  Each week, I was riveted to it.  It readily reflected the commodification and trivialization of plastic surgery. It was fantasy at its best, just as the phrase Nip’n’Tuck is. 

The phrase Nip’n’Tuck trivializes cosmetic surgery. Isn’t it time this phrase was retired? 

Cosmetic surgery is not a nip and a tuck. Cosmeticsupport.com agrees with Rajiv Grover and other BAAPS surgeons who are making the call that cosmetic surgery must be treated as a medical procedure and not a commodity. The surgeons making these calls are also calling for changes in advertising to stop the trivialization of surgery.  Why on earth do they still use the phrase Nip’n’Tuck as a media byline. How can we take their calls to reduce trivialization seriously enough to answer?  Double standards must stop. 

Why has it taken so long for calls to safety to be made? Thirteen years ago when I set up www.cosmeticsupport.com it was very clear that plastic surgery had been seriously commodified and yet nobody seemed concerned about it. Commercial clinics offering cosmetic surgery renamed their sales people ‘counselors’, abusing that title. Patients were misled and misinformed.  Patients believed they were seeing a counsellor when they were seeing a sales person.  Patients were put under enormous pressure to sign on the dotted line there and then in order to benefit from time-limited discounts. People were almost afraid not to have cosmetic surgery. Where were our hero surgeons then? Why was their voice not heard through all the years of tomfoolery in the industry? It has taken a long time for the call to change advertising to be made. Let’s hope that patients respond faster than they do. 

The scandalous drama of the PIP implants has caused everyone to sit up and take notice.  Professor Sir Bruce Keogh, Medical Director of the NHS launched an enquiry in August. The enquiry asked the public about their experiences and recommendations for the industry and whether the public wanted the changes to advertising which were being called for by the surgeons. I wrote to him and received a standard response from someone by email that gave no indication whether my original letter was ever read. The response was so underwhelming that it made me despair. 

Is it really true that in 2013, women are still not to be treated as equal human beings? Given that the PIP scandal affected women, one wonders if women have ever really earned the right to be treated seriously as human beings? How did the PIP scandal come about?  Who was really asleep at the switch? Surely we have enough safety committees in this country to spot an avalanche before it starts? We now know that mattress grade silicone was used to create breast implants when medical grade silicone should have been used.  Clinics who used these cheaper implants refused to take responsibility on behalf of their patients.  Why were so many women allowed to suffer like this? How was this allowed to happen?  It is as a result of the PIP Scandal that surgeons are making calls to change.  Who are they calling to?  Who are they calling for?  Are they fully versed at grass roots level where the patient is?  Will a change in advertising be enough to create safety for patients?  Why didn’t they call out over the many deaths through cosmetic surgery that have gone before?  Many people have died from complications from cosmetic surgery. Some died from badly trained surgeons performing profit-making surgery and some died from other complications, but the important point is that death occurred. Why did it take a disaster of such enormous proportion before we heard these surgeons making their calls for safety? I have been offering emotional support, voluntary, independent and non-profit, for 13 years and if this were not needed, I would not be offering it. Why don’t surgeons take more notice of what their patients really need? Protection must be in the mind as much as it is in the body. Support must be emotional as well as physical. Unlike many others offering this support, I am qualified to do so. 

I believe that surgeons who are making calls for safety would be wise to consider the history of patient support and safety that has gone before this situation in other arenas. For example, before an abortion, counselling is mandatory. This helps the patient put to rest all the issues that have come up for them before and after abortion. Different abortion clinics have different counsellors. Some are pro abortion and some are anti abortion and the patient who winds up with the wrong counsellor might find themselves seriously struggling emotionally for many years to come. However, existentially trained counsellors will not have an opinion on cosmetic surgery either way. These counsellors are trained to help the patient explore their issues, not to explore the counsellors views or issues. There is no religion involved in cosmetic surgery in the way that it is involved with abortion counselling. With the use of appropriate mandatory counselling, the message goes direct to where the safety is needed the most, to the patient. Surgeons will benefit by having a patient who is both well-informed surgically as well as personally. 

If all cosmetic surgeons in all clinics are obliged to offer cosmetic surgery counselling with fully qualified cosmetic surgery counsellors only then can patient safety truly be ensured. Patients will understand the different types of qualifications of different types of surgeons and understand what is involved in an informed choice. Some patients may decide to go ahead with their surgery with a better-trained surgeon than the one they have originally chosen.  Patients will have more time to consider all the information that is currently obscured by misleading information. No longer will sales people be allowed to call themselves ‘counselors’. Cosmeticsupport.com fully supports the idea that advertising in cosmetic surgery must change in order to reflect a more realistic perspective on what it is that people are choosing when they consider elective surgery. However, even with those changes in effect, patients still need a place to go where they can find objective support (counselling) to help them explore all the issues that are involved for them. Every patient will have their own set of issues before and after surgery. It would make an enormous difference to all patients if they were helped to explore their issues before and after cosmetic surgery. I believe that existential psychotherapy is the best-suited psychotherapy for this exploration as it is a philosophy concerned with the individual and his/her meaning in the world. Existential psychotherapy allows for an unbiased exploration of the individual’s world-view. 

(Existentially trained) cosmetic surgery counsellors will help to produce a more informed, relaxed patient because the patient will have clarified much confusing misinformation.  Patients will also have had the opportunity to explore all the ramifications of a particular type of elective surgery. Every patient has issues before and after a surgery and if the goal of the calls to change are to be heard, then the response must surely be for counsellors to be invited in to answer. 

Let’s nip trivialization in the bud and tuck in patient support.