No one is big enough to be independent of others.

—Dr William Mayo, founding brother of the Mayo Clinic

The founders of the Mayo Clinic in the late nineteenth century were medical practitioners who recognised the power of an alliance. In response to a medical crisis caused by a tornado, the doctors Mayo helped develop a community hospital that became the basis for the Mayo Clinic.

It was an early example of successful collaboration, bringing together colleagues considered the best in their respective fields. And it has endured to this day. As we expand as a specialty, and as we work on ever-widening fronts, it may be timely to reflect on the words of Dr William Mayo, founding brother of the Mayo Clinic: ‘No one is big enough to be independent of others.’

As a specialty we have engaged with multidisciplinary teams which undoubtedly has contributed to improvements in patient care. However, we have also struggled to embrace collaborations that cross geographic and disciplinary boundaries. While collaborative relationships across these boundaries may be difficult to achieve, they are critical to initiating real transformative change in patient care improvements.1 After all, it is the best patient outcomes that we are striving to achieve through our collaborative efforts.

This was articulated well by Michael Porter, an instigator of the international consortium for health outcomes measurement (ICHOM), who said that ‘any clinical activity should add true value to the patient being treated’.2 ICHOM is an example of excellent collaboration. It has drawn on networks of clinicians and other stakeholders to develop standardised ways of measuring and reporting patient outcomes; these have included craniofacial microsomia, cleft lip and palate and, most recently, breast cancer.3 These will allow health care providers globally to compare, learn and improve. Plastic surgeons have been pivotal to the success of these international initiatives by freely sharing their expertise with all other groups involved in the management of these conditions.

Unfortunately, not all collaborative efforts are embraced by some plastic surgeons. There are sensitivities about sharing our knowledge and skill-sets with other specialties, fearing it may lead to a diminution of our profile.

A prime example of this is the breast implant registry (BIR) that was founded in 1998 by Australian plastic surgeons in response to the Dow Corning crisis, which had gained momentum because scientific evidence from implanting surgeons was lacking. Like many other countries’ national plastic surgery societies, Australia developed an implant registry in a concerted attempt to avert any future implant crises from escalating through lack of data. Although the BIR was open to all implanting surgeons, it lacked true collaboration with other important stakeholders. When the next implant crisis occurred—the PIP issue in 2010—it escalated rapidly as the registry data was not of sufficient quality and reliability to mitigate against the prevailing emotional tension. We found that we were unable to advise government and regulators because the BIR’s implant capture rate was so low.4

This was a global phenomenon, not just an Australian issue, but it did prompt a national collaborative effort to revisit the registry issue with renewed vigour. Before we could re-build this registry, we had to cross a disciplinary boundary and engage Monash University’s Department of Epidemiology and Preventive Medicine. It soon became clear that we had to embrace registry principles that were counter-intuitive to plastic surgeons.

The new registry had to involve all practitioners involved in breast implant surgery including plastic surgeons, breast oncoplastic surgeons, cosmetic doctors, and others with a vested interest in breast implant surgery, including patient advocates, representatives from industry, regulatory experts from the Therapeutic Goods Administration (TGA) and personnel from the Commonwealth Department of Health. In addition, the consent process for patients was to be opt-out, the dataset to be collected was restricted to a bare minimum number of core data points, and an outcome measurement system was required to ensure this new registry qualified as a best practice clinical quality registry (CQR).5

It was true collaborative intent that made the new registry possible; the more we collaborated with this diverse range of experts, the more we learnt about other areas of knowledge, hitherto foreign to us.6 The new Australian breast device registry (ABDR) has shared the lessons learnt in its establishment with international plastic surgeons faced with the same challenge of building national breast implant registries.7 However, in order to be relevant internationally, there needed to be a minimum dataset with data definitions agreed upon by international plastic surgeon collaborators.8

With this in mind and with funding from the Australasian Foundation for Plastic Surgery (AFPS), an international collaboration of breast registry activities (ICOBRA) was formed by reaching over geographic boundaries to collaborate with international colleagues. By doing so, we can harmonise datasets, data definitions and outcome measures to facilitate registry data pooling globally.9 This ability to compare ‘like-with-like’ is particularly relevant as plastic surgeons around the world grapple with the causative factors of implant-related anaplastic large cell lymphoma.10 A further collaborative venture has seen the development of registry-specific patient reported outcomes measures (PROMs) derived from the BREAST-Q measurement system.11 Without meaningful collaborations, these concepts could not have been realised.

As the specialty of plastic surgery advances, it is to everyone’s benefit to have international connectivity. This goal is achievable through strong collaborative networks such as the newly formed international confederation of plastic surgery societies (ICOPLAST). This includes 63 countries and over 25,000 plastic surgeons. The purpose of ICOPLAST ‘is to enhance international communication, education, and advocacy processes to ultimately improve patient outcomes for plastic surgery patients globally.’12 International confederation of plastic surgery societies will also benefit plastic surgery as a profession, and each individual plastic surgeon.

The value of the new Australasian Journal of Plastic Surgery (AJOPS), which is itself a collaboration between the Australian Society of Plastic Surgeons and the AFPS, will be enhanced by having an international section to publish relevant articles on international collaborative efforts. Our international review panel includes leading plastic surgeons from 11 countries including Austria, Canada, Egypt, Germany, Japan, Malaysia, New Zealand, Netherlands, Sweden, the United Kingdom and the United States. Each member of the international reviewer panel has held prominent positions in their country’s national society and/or academic institutions. More importantly, all have been active collaborators with the Australasian plastic surgical community.

Australian and New Zealand plastic surgeons have been at the forefront of many innovations in plastic, reconstructive, and aesthetic surgery.13 They should maintain this prominent profile on the international stage by engaging with all stakeholders to improve outcomes for all patients in their care. This mission will be realised by harnessing the power of collaboration across borders of discipline and geography, locally, nationally and internationally.


The authors have no conflicts of interest to disclose.


The authors received no financial support for the research, authorship, and/or publication of this article.