Cosmetic surgery is a specialty exclusively dedicated to the enhancement of one’s appearance through surgical and medical techniques. Applications include all areas of the head, neck and body. Cosmetic surgery is defined as the choice to undergo an operation, or invasive medical procedure to alter one’s physical appearance for aesthetic rather than medical reasons.
The Department of Health, in its “Review of Regulation of Cosmetic Interventions” specified a need for a more robust regulatory framework that provides patients with enhanced protection against a variety of potential risks specific to cosmetic procedures. The main guidelines stipulate that products should be safe, practitioners should have appropriate training and skills, premises must be suitable, and patients must be treated with respect.
As a result of the review, The Royal College of Surgeons of England, led by a Cosmetic Surgery Interspecialty Committee (CSIC), has developed a certification scheme that provides a process for validating a variety of competencies, covering knowledgeability, clinical skills, professional behavior, and experience.
The British Association of Body Sculpting (BABS) is one of the professional bodies supporting the RCS initiatives, specifically in the area of cosmetic body contouring surgery. As part of its activities, the BABS runs a clinical fellowship program to help young surgeons learn cosmetic surgery skills in an approved and supervised clinical environment. Moreover, the BABS has implemented a Procedure Proficiency Program (P3) designed to independently verify the competency of each practicing cosmetic surgeon. The BABS issues a Cosmetic Surgery Competency (CSC) certificate to each surgeon that completes its training and assessment program.
This article documents the principles of the BABS Code of Practice and Conduct. It underpins that which is expected from BABS members, and those who hold the BABS Certificate of Competency and Conduct.
The key areas covered by this code include the processes of communication, patient consent, professional behaviour, and the proper handling of psychologically vulnerable patients.
This code supplements the broad principles set out in the GMC Guidance for Doctors Who Offer Cosmetic Interventions (GMC, 2016).
Public and Patient Education
The British Association of Body Sculpting (BABS) was formed from a peer support group of experienced body sculpting surgeons in 2010, and was transformed into a formal association, the BABS, in 2014. The goals of the association are to ensure that patients seeking body sculpting procedures have access to a wider range of information about body sculpting methods, to better understand whether body sculpting is appropriate for them, which technologies would be best adapted to their needs, the risks associated to body sculpting, and alternatives to these types of surgeries. The aim is also to inform patients about alternatives, such as healthy lifestyle options, non-surgical methods, and the importance of health over physical body shape. In particular, the association aims to promote psychological well being, and how to manage a healthy weight and a total body fat ratio, while understanding eating disorders, body dysmorphia and lipoedema.
Education and Training
Surgical body sculpting requires a deep knowledge and understanding of human anatomy and physiology, artistic understanding and appreciation of aesthetic body proportions for men and women, good surgical techniques and ethical practicing of medicine. Only doctors who poses all those attributes can deliver safe, effective and sustainable services to members of the public and satisfy their requirements. The association therefore adapted GMC's principles on standards of training and medical practice for doctors and made the specific code of practicing body sculpting and the training requirements for the surgeons including the operative skills and artistry of body sculpting. The specific attention was given to patient selection and recognising poor suitability for surgery, including psychological problems. This second aim of the association has as its goal for better trained and governed surgeons to be safer service providers and the public will at large benefit from that.
BABS also took as one of its function collection of adverse effects and outcomes of body sculpting, producing evidence based clinical guidelines and act as a Clinical Governance or Code of Conduct investigator in cases of patients complaint about doctors practicing body sculpting surgery.
3 Key Principles of the Code of Clinical Practice and Conduct
As for all doctors in all fields of medicine, a cosmetic surgeon must:
- Work in partnership with their patients, treating them with respect and dignity, in a non-discriminating manner.
- Keep patients safe, continuously working to improve safety and reporting all safety concerns.
- Collaborate effectively with colleagues.
- Remain up-to-date with relevant law and guidance (for example, regulations concerning patient confidentiality, adherence to the data protection act, and so on).
- Be open and honest about one’s skills, experience, fees and conflicts of interests.
In addition, cosmetic and body sculpting surgeons must:
- Directly seek the patient’s consent for surgery or any other cosmetic procedure, and not delegate this responsibility to a colleague.
- Ensure each patient is given sufficient information and time (the ‘cooling off period’) before making a decision to proceed with a cosmetic surgery intervention.
- Assess patient psychological needs using the BABS approved assessment tools, referring the patient to another experienced colleague when deemed appropriate.
- Recognize and work within the limits of one’s competency, and to seek advice when necessary.
- Ensure that patients have the information they want and need, including written documentation that gives relevant information about the medicines or devices used, aftercare provided, potential side effects of the procedure, and emergency contact details.
- Take exceptional care when consulting on interventions for children and young people.
- Market services responsibly, without making unjustifiable claims with regards outcomes, or trivialising the risks involved. Surgeons must not use promotional tactics that might encourage patients to otherwise make ill-considered decisions.
4 Knowledge, Skills and Performance
BABS members should make patient care their first concern.
- Cosmetic and body sculpting surgeons must recognize and work within the limits of their own competencies, and whenever appropriate, refer a patient to a colleague.
- Before carrying out an intervention for the first time, or supervising others performing it, surgeons must make sure they can do so safely, for example, through the BABS Clinical Fellowship or a through a procedure proficiency program.
- BABS members are required to participate in the educational activities of the organisation, as this constitutes a part of maintaining and developing their competencies and performance.
- It is the responsibility of BABS members to keep abreast of the updates in regulations and the law concerning clinical and ethical guidelines that apply to their work. All laws must be respected, as must be all GMC regulations and the BABS clinical guidelines relevant to their scope of work.
- Cosmetic and body sculpting surgeons must seek and act on feedback from patients, including information on their satisfaction and physical and psychological outcomes. This and feedback from colleagues, to their practice and improve the quality of their work.
- All members must undergo a BABS-administered annual appraisal for the body-sculpting procedures covered by their practice.
- All members who are cosmetic and body sculpting surgeons must keep a logbook of the cosmetic and body sculpting procedures they perform.
- Cosmetic and body sculpting surgeons must participate in an independent competency assessment credentialing process every five years through a procedure proficiency program.
5 Safety and Quality
- Cosmetic and body sculpting surgeons must participating in systems and processes that support patients safety, quality assurance and service improvement, as set out in Good medical practice and GMC’s related explanatory guidance. In particular, they must:
- Comply with any statutory reporting duties of the UK health services such as the CQC and the HMRA.
- Contribute to national programs to monitor quality and outcomes, including those of any relevant device registries (for example, implants, lasers, and so on).
- Routinely monitor patient outcomes, and participate in BABS annual audits, to reflect on their own practice, and to help gather national data audits on outcomes for body contouring cosmetic procedures.
- Report product safety concerns to the relevant regulator.
- Cosmetic and body sculpting surgeons should share insights and information about outcomes with their peers who offer similar interventions, to improve outcomes and patient safety.
- Cosmetic and body sculpting surgeons must inform patients how to report complications and adverse reactions.
- Cosmetic and body sculpting surgeons must be open and honest with patients in their care, or those close to them, if something goes wrong and the patient suffers or may suffer harm or distress as a result.
- Cosmetic and body sculpting surgeons must consult and assess patients according to the BABS guidance, and conduct the relevant standardized objective measurements, suitability assessment and psychological screening.
- Cosmetic and body sculpting surgeons must prescribe safely, and so must not therefore prescribe injectable medicines by telephone, video link, online or at the request of others for patients they have not examined.
- Cosmetic and body sculpting surgeons must seek and act on evidence about the effectiveness of the interventions they offer, and use this to improve their performance. They must provide interventions based on the best available up-to-date evidence about effectiveness, side effects and other risks.
- Cosmetic and body sculpting surgeons must ensure that the environment for their practice is safe, suitably equipped and staffed, and complies with all relevant CQC regulations.
6 Communication, Partnership and Teamwork
Cosmetic and body sculpting surgeons must communicate clearly and respectfully with patients, listening to their questions and concerns, and involving them effectively in each step of decision making.
Seeking patients’ consent
Cosmetic and body sculpting surgeons must be familiar with and follow the GMC’s guidance in Consent: patients and doctors making decisions together.
Responsibility for seeking consent for cosmetic interventions
The cosmetic and body-sculpting surgeon performing the procedure or surgery must discuss it with the patient and seek their consent him or herself. This responsibility must not be delegated to another person. This is essential to a shared understanding of expectations and limitations between the doctor and the patient.
Responding to patients’ requests for cosmetic interventions
- Cosmetic and body sculpting surgeons must take into consideration the patient’s medical history.
- Cosmetic and body sculpting surgeons must ask the patient why they would like to have the intervention and the outcome they hope for, before assessing whether the intervention is appropriate and likely to meet their needs.
- Cosmetic and body sculpting surgeons must follow the best practice guidelines set by the BABS, and to elicit the patient’s objectives from the cosmetic surgery by examining with the patient various case studies of patients of similar age and body morphology.
- If cosmetic and body-sculpting surgeons believe that the intervention the patient is seeking is unlikely to deliver the desired outcome or to be of overall benefit to the patient they must discuss this with the patient and explain their reasoning. If, after discussion, surgeons still believe the intervention will not be of benefit to the patient they must not provide it. Cosmetic and body sculpting surgeons should discuss other options available to the patient and respect their right to seek a second opinion.
- Cosmetic and body sculpting surgeon must consider patients’ vulnerabilities and psychological needs, and be satisfied that a patient’s request for the cosmetic intervention is voluntary.
- Cosmetic and body sculpting surgeons must explain any monitoring or follow-up care requirements from the outset. They must tell patients if implanted medical devices may need to be removed or replaced and after how long.
- Cosmetic and body sculpting surgeons must tell prospective patients if alternative interventions are available that could meet their needs with less risk, including from other practitioners.
Discussing side effects, complications and other risks
- Cosmetic and body sculpting surgeons must give patients clear, accurate information about the risks of the proposed intervention and any associated procedures, including anesthesia and sedation.
- Cosmetic and body sculpting surgeons must talk to the patient about any adverse outcomes that may result from the proposed intervention, paying particular attention to those the patient is most concerned about.
- Cosmetic and body sculpting surgeons must talk about the potential adverse physical and psychological impact of the intervention going wrong or failing to meet the patient’s expectations.
- Cosmetic and body sculpting surgeons should illustrate adverse effects by showing appropriate case studies.
Giving patients time for reflection
- Cosmetic and body sculpting surgeons must give the patient the time and information they need to reach a voluntary and informed decision about whether to go ahead with an intervention.
- Cosmetic and body sculpting surgeons must allow the patient sufficient time for reflection for a body contouring or cosmetic surgical procedure. The amount of time needed and the amount and type of information provided will depend on several factors. These include the invasiveness, complexity, permanence and risks of the intervention, how many intervention options the patient is considering and how much information they have already considered about a proposed intervention.
- Cosmetic and body sculpting surgeons must tell the patient they can change their mind at any point.
- Cosmetic and body sculpting surgeons must consider whether it is necessary to consult the patient’s GP to inform the discussion about benefits and risks. If so, they must seek the patient’s permission and, if they refuse, discuss their reasons for doing so and encourage them to allow their GP to be contacted. If the patient is determined not to involve their GP, the surgeon must record this in their notes and consider how this affects the balance of risk and benefit and whether they should go ahead with the intervention.
Being clear about fees and charges
- Cosmetic and body sculpting surgeons must explain their fees clearly, so patients know the financial implications of any decision to proceed to the next stage or to withdraw.
- Cosmetic and body sculpting surgeons must be clear about what is included in quoted prices, and what other charges might be payable, including possible charges for revision or routine follow up.
Treating adult patients who lack capacity
- Generally, cosmetic and body sculpting surgeons should avoid offering cosmetic treatments to patients who they believe are unable to give a full informed consent to treatment.
- However, if after taking into account the views of people close to the patient, as well as any information the surgeon and the healthcare team may have about the patient’s wishes, feelings, beliefs and values, it may be suitable to proceed with a patient who lacks capacity.
- Under these circumstances, cosmetic and body sculpting surgeons must include those close to the patient in the consultation process, and should follow the advice on sharing information set out in patient confidentiality guidelines, respecting minimum necessary disclosure in the interest of the patient.
- Cosmetic and body sculpting surgeons must have, and follow a written policy on dealing with vulnerable adults.
Treating children and young people
- Cosmetic and body sculpting surgeons should take particular care if they consider providing cosmetic interventions for children or young people.
- Cosmetic and body sculpting surgeons should make sure the environment for practice is appropriate to paediatric care, and work with multidisciplinary teams that provide expertise in treating children and young people where necessary (that is, Child Protection Level 3 trained).
- Cosmetic and body sculpting surgeons must only provide interventions that are in the best interests of the child or young person. If a young person has capacity to decide whether to undergo an intervention (see Gillick and Fraser competence assessment), the surgeon should still encourage them to involve their parents in making a decision.
- A parent can consent to an intervention for a child or young person who does not have the maturity and capacity to make the decision. However, cosmetic and body sculpting surgeons should involve the child in the decision as much as possible. If cosmetic and body sculpting surgeons judge that the child does not want to have the cosmetic intervention they must not perform it.
- Cosmetic and body sculpting surgeons must not market treatments targeting children or young people, either through their content or placement.
Providing continuity of care
- Cosmetic and body sculpting surgeons should consider whether a patient will need following treatment, and must make sure the patient understands the timings for follow-up appointments.
- Cosmetic and body sculpting surgeons must follow guidelines on post-operative care, follow up and support as according to the BABS’s recommendations.
- Cosmetic and body sculpting surgeons must make sure the patient has the medicines or equipment they need to care for themselves after an intervention, and they should be given comprehensive written instructions on self-care and aftercare.
- Cosmetic and body sculpting surgeons must make sure that their patients know how to contact them or another deputized, named, suitably-qualified person if patient experiences complications outside of normal working hours for the surgeon.
- Cosmetic and body sculpting surgeons should give patients written information that explains the intervention they have received in enough detail to enable another doctor to take over the patient’s care. This should include relevant information about the medicines or devices used.
- Cosmetic and body sculpting surgeon should also send this information, with the patient’s consent, to their GP, and any other doctors treating them if it is likely to affect the patient’s future healthcare. If the patient objects to the information being sent to their doctor, cosmetic and body sculpting surgeons must record this in their notes and they will be responsible for providing the patient’s follow-up care.
- Cosmetic and body sculpting surgeons should organize patients’ records in a way that allows identification of patients who have been treated with a particular device or medicine in the event of product safety concerns or regulatory enquiries.
- Cosmetic and body sculpting surgeons must keep records that contain personal information about patients securely and in line with:
- Any data protection requirements
- GMC Confidentiality guidance
- Guidance published by the UK health departments
Working with colleagues
- Cosmetic and body sculpting surgeons must make sure that anyone they delegate care of patents to has the necessary knowledge, skills and training, and is appropriately supervised.
- Cosmetic and body sculpting surgeons must work effectively with healthcare professionals and others involved in providing care to their patients.
- Cosmetic and body sculpting surgeons must respect the skills of colleagues involved in providing care, support them, and never deliberately undermine their reputations.
- Cosmetic and body sculpting surgeons must ask for advice from colleagues if the patient has health needs that lie outside their field of expertise.
- Cosmetic and body sculpting surgeons must make sure they build a support network of experienced professional colleagues who can advise them, and in turn they must participate in providing peer support.
- Cosmetic and body sculpting surgeons should ask for advice when they treat patients who may need psychological or other expert assessments or support.
7 Maintaining Trust
Cosmetic and body sculpting surgeons must always be honest and never misleading about their skills, experience, qualifications, professional status and current role.
Communicating information about services
- When advertising their services, cosmetic and body sculpting surgeons must follow the regulatory codes and guidelines set by the Committee of Advertising Practice in the UK.
- Cosmetic and body sculpting surgeons must make sure the information they publish is factual and can be checked, and does not exploit patients’ vulnerability or lack of medical knowledge.
- Cosmetic and body sculpting surgeons must be responsible in marketing. They must not minimize or trivialise the risks of interventions and must not exploit patients’ vulnerability.
- Cosmetic and body sculpting surgeons must not claim that interventions are risk free.
- Cosmetic and body sculpting surgeons must state clearly in their marketing if patients will need to have a medical assessment before the surgeon can carry out an intervention.
- Cosmetic and body sculpting surgeons must not mislead about the results the patients are likely to achieve.
- Cosmetic and body sculpting surgeons must not falsely claim or imply that certain results are guaranteed from the treatment.
- Cosmetic and body sculpting surgeons must not use promotional tactics in ways that could encourage people to make an ill-considered decision.
- Cosmetic and body sculpting surgeons must not provide their services as a prize that can be won.
- Cosmetic and body sculpting surgeons must not knowingly allow others to misrepresent them or offer their services in ways that would conflict with this guidance.
Honesty in financial dealings
- Cosmetic and body sculpting surgeons must be open and honest with their patients about any financial or commercial interests that could be seen to affect the way they prescribe, advise, treat, refer or commission services for them.
- Cosmetic and body sculpting surgeons must not allow their financial or commercial interests in a cosmetic intervention, or an organization providing cosmetic interventions, to affect their recommendations to patients or their adherence to expected good standards of care.
Adherence to the code of practice Requirements
- Adherence to the Code of Practice is enshrined in the Charter of the association.
- When joining BABS, new members sign a statement agreeing to adhere to the code of practice.
Verification of compliance process and pathways
- Compliance is verified during annual appraisals
- If a doctor's performance data significantly deviates from average statistics for of their peers the Clinical Governance Lead initiates a detailed assessment of the doctor’s practices, requiring the doctor’s last 5 surgical records, and conducting interviews. The process results in a written recommendation.
- Patient complaints and feedback may also trigger closer scrutiny to evaluate if a doctor’s practice follows agreed standards.
- A doctor may ask for a help.
- The GMC or CQC might ask for an evaluation of a doctor’s performance.
- An insurance company or a legal representative might ask for an opinion on a doctor's performance.
- All BABS members have a clinical 'buddy’ (a mentor/peer) for support, and to avoid practicing in isolation.