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Identifying red flags in cosmetic and reconstructive surgery candidates

21 Mar 2023, by Amy Sarcevic


An experienced cosmetic or reconstructive surgeon knows that various cohorts of people are not good candidates for surgery, for reasons other than their physical health.

People who live with mental health conditions, abusive partners, or who have unrealistic expectations, often become dissatisfied with the outcome of surgery, irrespective of how well the procedure has been performed.

This can cause untold psychological harm to individuals and, in the extreme, result in litigation. In Australia, around 16 percent of all healthcare disputes relate to cosmetic surgery. Of these, 39 percent of patients claim the surgeon failed to explain the potential lack of benefit; and 26 percent allege they were improperly informed before consent.

Surgeon and Director of the Australasian Foundation for Plastic Surgery (AFPS), Dr Garry Buckland, along with a team of psychologists in the UK, are helping to address this with a world-first psychological assessment tool.

The web-based tool, which is only available to clinicians, contains thirteen questions that capture issues like mental health, intimate partner relations, body image and people’s relationship with social media – all of which influence a person’s expectations of surgery.

It aids surgeons to make real time and accurate decisions about who to refer for psychological or psychiatric assessment before surgery is further considered; and helps identify people who should not pursue surgery at all.

Dr Buckland who also is a hearing member of the NSW Medical Board has witnessed first-hand the outcomes that result from poorly considered surgeries and says it is time some objectivity was brought to these assessments.

“Our research has shown that 30 percent of people would benefit from further assessment or education prior to considering surgery. This cohort might have anxiety, depression, an eating disorder, or body image issues that teenagers and young adults struggle with on a day-to-day basis that have been exacerbated by social media. A much smaller number have vulnerabilities that should altogether exclude them from surgery, like body dysmorphic disorder.

“Currently, pre-surgical assessments for these issues are rare and, when they do occur, can be specific to only one risk factor. In contrast, our tool has undergone testing in clinical practice and allows surgeons to assess for wellbeing ‘red flags’ in an evidence-based and objective fashion”

To boost validity, the survey has been designed in a way that maximises the chances of people giving honest answers.

“A great deal of time has been spent refining the questions so that they are comprehensive and practical enough to identify all possible red flags; but not so detailed and small that they lose all of their clinical relevance and practicality.”

Given the tool’s objectivity, Dr Buckland believes even the most astute and ethically-minded, surgeons will benefit from using it in everyday practice.

“Every clinician has a sense of what spikes their radar in terms of patient wellbeing. However, I’ve been doing this job for twenty years, and on plenty of occasions I’ve assessed people as having no vulnerabilities and later been proven wrong. Some are simply better hiding their vulnerabilities than others.”

Dr Buckland stressed that adhering to the tool will not be a legal obligation, but that it will allow surgeons to operate more ethically and uphold their reputation. It could also reduce the threat of litigation, by identifying candidates who present as a vulnerable patient.

He believes the vast majority of candidates who undergo the test will pursue surgery, but with appropriate information, higher levels of support and more realistic expectations.

“It isn’t about excluding people and reducing the number of people who have surgery, but rather ensuring people are adequately supported in their surgical journey.

“This is just as important for people who have reconstructive surgery, as they can be equally vulnerable as those seeking surgery purely for cosmetic reasons.”

Dr Buckland says the tool could also help people in other specialties, within which the perceived outcome can be impacted by the patient’s body image. This could include bariatric, ear, nose and throat surgery, or procedures to correct congenital anomalies.

“Essentially any type of surgical specialty that involves altering someone’s appearance would benefit from using this tool,” he said.

Dr Buckland and team – which includes renowned psychologists Emeritus Professor Nichola Rumsey and Dr Alex Clarke – are due to meet with Australian regulators in the coming weeks and are pleased that the five year project may now be coming to a head.

“After years of hard work, our tool will soon be at the stage of making its way into mainstream practice. It’s an exciting time,” he said.

Dr Buckland is a consultant specialist in plastic, cosmetic, and reconstructive surgery, with extensive experience in all aspects of the specialty. He is a Fellow of the Royal Australasian College of Surgeons (FRACS) and a member of the Australian Society of Aesthetic Plastic Surgeons (ASAPS).

Hear more from him at the Cosmetic Surgery Safety Conference, where he will talk more about this and other initiatives his organisation is pioneering to improve patient outcomes.

This year’s event will be held 14-15 June at the PARKROYAL Sydney.
Learn more and register your place here.


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