Specialist plastic surgeons, politicians, journalists and many others are concerned for the safety of Australians undergoing cosmetic surgery by medical practitioners who have not had specialist surgical education and training accredited by the Australian Medical Council (AMC). There is an excellent reason for surgeons and anaesthetists to have the rigorous training that our colleges deliver. It is so high-quality surgical procedures are undertaken as safely as possible by well-trained surgeons, anaesthetists, nurses and other health professionals in facilities with high safety and hygiene standards, using quality devices, drugs and supplies.

Cosmetic surgery is the same as all other surgery. All surgery, whether it is neurosurgery, orthopaedic surgery or general surgery, involves cutting through tissues, dissection, protection of anatomical structures, reliable performance of the required procedure and safe ‘closure’. For this to occur, surgeons have advanced along a pathway of medical school, internships, several years of in-hospital registrar work, competitive selection into structured, supervised training positions in accredited hospitals, with requirements to experience the whole breadth of their specialty. Trainees and surgeons attend important courses along the way and pass high-stakes examinations.

The Royal Australasian College of Surgeons (RACS) has mapped surgical training and experience to ten competencies.1 Plastic surgery in Australia has made significant moves toward competency-based training (CBT) with units of professional practice (entrustable professional activities or EPAs) incorporating several RACS competencies. Surgical training is much more than technical expertise. If that were the case, training would be easier and only taught in an operating theatre, via computer simulation and online. RACS qualified surgeons learn how to care for the total patient. We listen, communicate and learn teamwork, shared decision-making, patient-centred care, informed consent, informed financial consent, perioperative care, pre- and postoperative counselling and how to manage complications and variations in outcomes. People who have been our patients return to us for further review during their lifetime. Our trainees, and many surgeons, undertake research. We audit our work and learn for ourselves and with our peers. We continually learn and maintain our knowledge and skills over our careers.

Cosmetic surgery is different from all other surgery. Cosmetic surgery is not undertaken to treat a disease or functional problem but to achieve what the patient perceives to be a more desirable appearance or where the procedure involves changes to bodily features that have a normal appearance.2 Cosmetic surgery is voluntary, self-directed—a person’s choice. It is self-funded. Cosmetic surgery is a commercial business with financial drivers for the business to do well and deliver the procedures that generate income. There is potential for cosmetic medical practitioners to assess and counsel their patients inadequately.

With the internet and social media, there is far greater awareness of the possible changes that cosmetic surgery can achieve for people. Advertising is ubiquitous; it reaches a younger population more than ever before. It causes people to question their appearance and believe they can easily change their faces and bodies to achieve the desired outcome. People take risks. With the manipulation of photographic images, advertising can be misleading and fraudulent. Before and after photographs might not be taken in similar light or position, giving the false impression of the desired change. Photographic representations of possible cosmetic interventions may not be achievable or realistic. Testimonials are currently banned and hopefully that will be maintained. They are not necessarily true accounts and might not be verifiable.

Cosmetic surgery should be subject to the same rules and regulations as all other types of surgery. Unfortunately, complaints or notifications of concerns about complications or poor outcomes of cosmetic surgery, whether real or perceived, and professional misconduct, sometimes go unregistered due to issues with patients and medical practitioners. It has been said that several of the dramatic life-threatening complications recently depicted in the media have not been notified. This is a reminder to register notifications with the regulator so they can be recorded and investigated. We should be ready to speak up for patient safety. We would like to see action to stop unsafe cosmetic surgery.

The Australian Health Practitioner Regulation Authority (Ahpra) Medical Board of Australia (MBA) report on medical practitioners who perform cosmetic surgery was released in August 2022 with 16 recommendations.3 One of these is endorsement as a way for medical practitioners to be approved to practise cosmetic surgery. The Royal Australasian College of Surgeons, the Australian Society of Plastic Surgeons (ASPS), the Australasian Society of Aesthetic Plastic Surgeons (ASAPS), and the Australian Society of Otolaryngology, Head and Neck Surgery (ASOHNS) are all concerned about this recommendation. There is no ‘minor’ cosmetic surgery which can be learned in a short course. All the surgical operations that plastic surgeons do require years of training, as described above and as documented in the plastic surgery curriculum. We suspect that the time it will take to set up such a course will be too long to be relevant. The process of course and curriculum development, faculty recruitment, programing then application to the AMC for accreditation will take many years. At RACS, we know that AMC accreditation is a huge and expensive project requiring the constant involvement of several staff members and RACS councillors over many years. A group will have to be prepared to go through this.

We are now at a critical point. We have the attention of the federal Minister for Health and Aged Care, the Honourable Mark Butler MP, and a new government. Surgery, including cosmetic, should be performed by trained specialist surgeons. We accept that specialist GPs undertake some surgery such as wound care and cutaneous malignancy care. Rural GPs perform a range of other surgical procedures. Dermatologists also have a significant role in skin cancer care. Our AMC accredited surgical colleagues—ophthalmologists, obstetric and gynaecologists and oral maxillofacial surgeons—each have an element of cosmetic surgery in their specialty.

All registered medical practitioners in Australia can use the titles ‘surgeon’ and ‘cosmetic surgeon’.4 All are expected to comply with the MBA’s code of conduct 3.2.1 Recognising and working within the limits of your competence and scope of practice and 3.2.2 Ensuring you have adequate knowledge and skills to provide safe clinical care.5 Based on these statements of the standards of professional conduct, surgical training accredited by the AMC is the absolute requirement. We are still awaiting the Health Council’s decision on the use of the title ‘surgeon’, but we have had positive comments from the Hon Mark Butler MP that he will restrict the use of the title ‘cosmetic surgeon’. We await the verdict on the use of the title ‘surgeon’, which should be restricted to medical practitioners who have undergone an AMC accredited training program with a significant surgical training component. These clarifications regarding titling are essential to ensure the public are not being misled as to which medical practitioners are trained to the accepted standard for their safety.

As plastic surgeons, we read about the deaths from a particular cosmetic surgery procedure, the ‘Brazilian butt lift’ (BBL), performed mainly in the USA in Florida. Anatomical dissections of eleven autopsies (22 buttocks) showed that all had fat injected into the gluteal muscles at multiple levels.6 The advice is to inject in the subcutaneous plane and not the muscle. Of the BBL deaths, 92% were performed at high-volume, budget clinics and resulted from short surgical times of approximately 90 mins.6 No deaths occurred with board-certified plastic surgeons. We must not allow this—the deaths of young women having a major surgical procedure—to happen. The deaths have continued in the USA despite guidance from the Aesthetic Surgery Education and Research Foundation (ASERF) 2017.7

The required crackdown on inadequately trained medical practitioners performing cosmetic surgery must occur and soon. The Royal Australasian College of Surgeons, with ASPS, ASAPS, and ASOHNS surgical leadership, will continue to work with and advise the Australian Government and regulators on ways to implement these changes. As trained surgeons, we are privileged to offer safe surgery—including safe cosmetic surgery—to our community.