The implications of the new guidelines on medical practitioners who perform cosmetic surgery and procedures

25 May 2023

Background

From 1 July 2023 onwards, medical practitioners who perform cosmetic surgery and procedures will be subject to updated guidelines developed by the Medical Board of Australia (Medical Board) under section 39 of the Health Practitioner Regulation National Law (the National Law).

The new guidelines were developed in response to an independent review into the regulation of medical practitioners who perform cosmetic surgery (Independent Review), commissioned by the Medical Board and the Australian Health Practitioner Regulation Agency (AHPRA) in November 2021. The Independent Review was commissioned following the emergence of issues in the cosmetic surgery area; the independent reviewer was Mr Andrew Brown, former Queensland Health Ombudsman, with an expert panel.

On 1 September 2022 AHPRA published a Final Report following the Independent Review. The Final Report made 16 recommendations which were all accepted by AHPRA and the Medical Board. We discuss the significance of the new guidelines below.
 

Education, Training and Qualifications

One of the prominent changes to the current guidelines relates to education, training and qualifications. The current guidelines require practitioners who perform cosmetic medical and surgical procedures to have “the appropriate training, expertise, and experience to perform the procedure and deal with all routine aspects of care and likely complications”.[1] The Independent Review concluded that the current guidelines in this respect were unsatisfactory. The Independent Review considered that the non-existence of minimum standards for education, training and qualification for cosmetic surgery in Australia meant the onus was on patients, in their capacity as a ‘consumer’, to navigate through marketing materials to find a practitioner that they considered possessed the relevant qualifications and expertise to perform the surgery sought.[2]

In light of the above, the new guidelines have been developed to ensure that:

Cosmetic surgery must only be provided by medical practitioners with the appropriate knowledge, training and experience to perform the surgery and deal with all routine aspects of care and any likely complications. (When area of practice endorsement for cosmetic surgery is available) an approved qualification eligible for endorsement for cosmetic surgery is appropriate training. In the interim, the Board expects that at a minimum, a medical practitioner providing cosmetic surgery will have undertaken appropriate surgical skills training, training in the specific cosmetic surgery being offered, and have completed supervised practice to ensure they are safe to perform the surgery.[3]

The guidelines have also been updated to ensure that if cosmetic procedures fall within a practitioner’s scope of practice, the medical practitioner is required to complete continuing professional development (CPD) on ‘activities related to cosmetic surgery, including reviewing their performance and measuring their outcomes’[4]. This is a departure from the current guidelines, whereby there is no requirement for CPD to relate specifically to cosmetic procedures.
 

Financial arrangements

Another change to the current guidelines relates to financial arrangements. The current guidelines state that a patient must be provided with information pertaining to the costs of the procedure, practitioners should ensure that they do not have a financial conflict of interest, and practitioners should not provide or offer:

• financial inducements to agents for recruitment of patients;

• financing schemes; and

• additional products.

The new guidelines see a tightening of financial arrangements, and have expanded to prohibit practitioners from:

• providing or offering to provide free or discounted surgery to prospective patients via promotion of the services; and
• encouraging taking on of a debt, such as a personal loan or re-mortgage, or access their superannuation to pay for the procedure.

The new guidelines specify that practitioners will not be precluded from providing a patient with information about credit cards, buy now, pay later products or from offering instalment payment options in a non-commercial arrangement.
 

What surgeries and procedures will these new guidelines apply to?

The new guidelines define “Cosmetic Surgery and Procedures” as “operations and other procedures that revise or change the appearance, colour, texture, structure or position of normal bodily features with the dominant purpose of achieving what the patient perceives to be a more desirable appearance”. “Cosmetic Surgery is defined as “involves cutting beneath the skin. Examples include breast augmentation, abdominoplasty, rhinoplasty, blepharoplasty, surgical face lifts, cosmetic genital surgery, and liposuction and fat transfer.” Non-surgical cosmetic procedures are defined as “does not involve cutting beneath the skin but may involve piercing the skin. Examples include cosmetic injectables such as Botulinum toxin and dermal fillers (also known as soft tissue fillers), fat dissolving injections, thread lifts, non-surgical cosmetic varicose vein treatment, CO2 laser skin resurfacing, cryolipolysis (fat freezing), laser hair removal, dermabrasion, chemical peels, microsclerotherapy and hair transplants. Mole removal for the purposes of appearance is classified as non-surgical even though it may involve cutting beneath the skin”.

Whilst the new guidelines are significant, they do not extend to all cosmetic surgery and procedures. The following are excluded from the definitions:

• Reconstructive surgery, as it restores form and function as well as normality of appearance;
• Surgeries or a procedure with a medical justification, even if the result may lead to an improvement in appearance; and
• Gender affirmation surgery.

The new guidelines otherwise state that a surgery or a procedure may be medically justified where it “involves the restoration, correction or improvement in the shape and appearance of body structures that are defective or damaged at birth or by injury, disease, growth or development for either functional or psychological reasons”.
 

What cosmetic surgeons need to know

Significant implications of the new guidelines for medical practitioners performing cosmetic surgery and procedures are that:

• patients seeking cosmetic surgery must be referred by a medical practitioner who works independently from the practitioner performing the surgery (preferably the patient’s usual general practitioner);
• following referral, patients will need to have a minimum of two pre-operative consultations, one of which must be in person with the practitioner performing the surgery. This practitioner will be required to assess the patient for psychological conditions using a validated psychological screening tool for any conditions that may make them an unsuitable candidate for surgery. This practitioner must also discuss the patient’s motivations for requesting surgery and expectations for the surgery to ensure they are realistic;
• if the practitioner considers that the patient has significant underlying psychological issues which may make them unsuitable for the requested surgery, they will be required to refer the patient for evaluation to a psychologist, psychiatrist or general practitioner;
• if it is considered that the patient is a suitable candidate for surgery, a cooling off period of at least 7 days is required before the surgery can be booked or a deposit paid; and
• the practitioner performing the surgery must further advise patients of their right to make a complaint should they be dissatisfied with the outcome of the procedure and provide all information before the surgery about the complaints mechanisms available.
   

Conclusion

The new guidelines appear to be informed by the understanding that medical conditions such as body dysmorphic disorder may inhibit a patient’s capacity to appreciate the potential risks associated with cosmetic surgery and hence provide informed consent. The new guidelines also take into account the emergence of marketing schemes, such as by way of social media influencing or provision of additional gifts, which may in effect entice patients to undergo cosmetic procedures without careful consideration of the relevant risks and complications associated with the surgery or procedure, or without regard to the financial consequences. It is noted in the guidelines that they can be used to assist the Board in its’ role of protecting the public by setting and maintaining standards of medical practice.[5]