Cosmetic compliance

complianceCosmetic compliance

Industry guidelines have been put in place to ensure patients make informed decisions about cosmetic treatment, but many websites use aggressive marketing to entice new customers. Dr Sohaib Rufai and Mr Christopher Davis investigate whether providers and cosmetic surgeons are complying with the latest regulations


The cosmetic surgery industry is booming, with a reported 15 million people worldwide undergoing surgery in 2011. However, Hippocrates’ words, “first do no harm”, are especially relevant in cosmetic surgery, where harm can include risks and complications for the patient as well as legal repercussions and a negative reputation for the surgeon.

High-profile examples of these risks include: the death of footballer Colin Hendry’s wife after liposuction inadvertently resulted in bowel perforation and fatal infection; a Surrey businesswoman receiving a £6million legal pay-out after complications from a facelift; and the death of rapper Kanye West’s mother following breast reduction and abdominoplasty.

“Book now and save up to 15%.” “You too can be happy! Limited offer on breast implant surgery for the first 50 customers.” “We even provide a complimentary chauffeur service!” Aggressive marketing techniques and enticing cosmetic surgery offers like these have unfortunately become widespread on the internet, luring patients towards potentially impromptu decisions.


In a bid to safeguard patients and regulate the UK’s cosmetic surgery industry, the Department of Health (DH) and Cosmetic Surgical Practice Working Party (CSPWP), based at the Royal College of Surgeons of England, set out the following guidelines for cosmetic surgical practice:

• Consultations with a medical professional rather than a sales “consultant”

• Banning free consultations

• Restricting time-limited promotional deals

• Two-stage written pre-operative consent

• A two week cool-off period

We performed a study, essentially putting ourselves in a potential patient’s shoes—browsing the internet in search of a cosmetic surgeon to consult. We looked at the top fifty Google-ranked companies and quantified their compliance with the national safety guidelines above.

We studied their websites and called the clinics to assess individual compliance against each guideline. Unfortunately, the overall compliance with all the above guidelines was only 41%.

Sales consultants

Five of the providers in the study (10%) offered consultations with an individual other than a plastic surgeon. Of these providers, three were offered with patient care coordinators—or sales consultants—while two consultations were offered with specialist nurses.

An ethical issue exists if patients are coaxed into the first stage of the decision-making process before meeting the operating surgeon to discuss their risks on a case-by-case basis. Specific examples included companies taking a deposit for a procedure during the initial consult as part of a “special discount” for the patient.

Free consultations

The majority (54%) of providers in this study offered free consultations. It is unclear how much of a factor this plays in putting patients under pressure to proceed with cosmetic surgery. According to the DH review, free consultations may make a patient feel obliged to proceed with the operation, while a nominal consultation fee encourages impartial advice about the risks and benefits of surgery.

One provider charged a small consultation fee and donated this to charity, in order to meet this guideline. On further questioning during our telephone follow-up with providers, a proportion justified their complimentary consultations on the basis that it felt unreasonable and too “business-like” to charge for the service.


Promotional deals were offered by 52% of the providers. Of these, 27% were time-restricted deals. The DH Review encourages banning time-limited deals due to the risk of enticing and pressurising patients into undergoing a cosmetic procedure.

Another pattern of promotions identified were “multibuy” packages, including mother and daughter discounts and bridal packages. Again, these offers could potentially entice patients into undergoing more surgery than first intended. Finally, certain providers offered free chauffeurs and photoshoots in an attempt to glamorise cosmetic surgery.

Two week cool-off period

Only 62% of providers stipulated a compulsory two week cool-off period to give the patient time to think about their decision, discuss their options informally and weigh up the risk-benefit ratio of surgery. Some providers explained by telephone that this two week cool-off is simply a suggestion and can be waived if the patient signs a disclaimer in the first visit.

Two-staged consent

We were surprised to find that none of the top fifty Google-ranked cosmetic surgery providers at the time of this study stipulated a two-staged consent process. The DH and CSPWP recommend two-staged signed consent to ensure the patient is absolutely sure of their decision before proceeding.


This study elucidated the poor compliance of a sample of cosmetic surgery providers with national safety guidelines. Aesthetic surgery offered by fully trained plastic surgeons—who were often affiliated with the British Association of Aesthetic Plastic Surgeons—was generally more compliant than that of the major cosmetic surgery companies.

The question of whether these guidelines are realistic and appropriate for safeguarding patients remains, especially when many providers continue to use aggressive marketing techniques and enticing offers, regardless of the recommendations.

We recommend a dialogue between cosmetic surgery providers and government regulators to agree on tighter controls and mandatory regulations to limit unprofessional practice and maximise patient safety.

The full research paper was published in the Journal of Plastic, Reconstructive and Aesthetic Surgery in May 2014. Sohaib R. Rufai is a final year medical student at the University of Southampton. His supervisor, Dr Christopher R. Davis, works in the Division of Plastic & Reconstructive Surgery at Stanford University, CA. E:;



1. Bates C. “15million people worldwide had plastic surgery in 2011… but why ARE South Koreans so much more likely to go under the knife?” The Daily Mail. 31st January 2013.–SOUTH-KOREA-leading-way.html

2. Taylor J. “Ex-football star’s wife dies after botched plastic surgery.” The Independent. 10th July 2009.

3. Quinn B. “Surrey businesswoman wins £6m payout over botched facelift.” The Guardian. 23rd May 2011.

4. Hernandez A. “Donda West Died of Heart Disease after Surgery.” People Magazine. 1st October 2008.,,20170370,00.html

5. Department of Health. “Review of the Regulation of Cosmetic Interventions.” 2013.

6. Cosmetic Surgical Practice Working Party. “Professional Standards for Cosmetic Practice.” 2013.

7. Rufai SR, Davis CR. “Aesthetic surgery and Google – ubiquitous, unregulated and enticing websites for patients considering cosmetic surgery.” Journal of Plastic, Reconstructive and Aesthetic Surgery. 2014 May;67(5):640-643.

Author: bodylanguage

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