A few weeks ago, I set out to write a series of posts on LinkedIn to record an evolving expose of the degradation of professionalism in some leading figures in Australian Plastic and Reconstructive Surgery.
LinkedIn is not so good at archiving material; it is better for promotion and marketing. Accordingly I have changed my strategy... back to the blog.
Writing a blog is quite an adventure. I feel so privileged to have this platform on the PMFA Journal website. What an archive of outspoken and evidence-based opinion covering a wide range of issues but focusing on medico-legal cases and professional ethics.
I have been quiet for a bit while relocating to the UK and renovating a house and a garden. I do however maintain an international medico-legal consultancy based on Hong Kong and in that context, I did receive some fascinating instructions from solicitors in Australia.
Looking at the current litigation and in particular a class action lawsuit against The Cosmetic Institute (TCI) [1], I have been able to examine the 'expert opinions' of certain Royal Australian College of Surgeons (RACS) Board Certified and Accredited Plastic and Reconstructive Surgeons. I have found them to be shameful and dishonest – there were three of them, all hopelessly flawed.
The TCI case is fascinating as it really brings into focus the ethical dilemmas when searching for a moral and professional framework for cosmetic surgery. TCI decided to focus on a very narrow but highly lucrative market: cosmetic breast augmentation. In a five-year period, they performed over 16,000 cases with the vast majority of patients satisfied.
Despite extensive publicity, a 'no-win, no fee' firm of lawyers claimed to have identified (only) 200+ complications [2] – an incredibly low complication rate. As I shall be discussing in later blogs there is unequivocal evidence that some of the so-called complications were artificially created by highly conflicted 'experts'. This is a fascinating case made more complex by the number of subplots. There are the obvious turf wars with the RACS surgeons claiming competences that they do not have.
Plastic surgery is not the same as cosmetic surgery. This needs to be stated and restated.
Australian RACS Accredited Plastic and Reconstructive Surgeons are not presented with opportunities to develop and acquire operative skills in independent cosmetic surgery during their training in plastic surgery. The same can be said for plastic surgery trainees in the UK. This is not to criticise the training given in plastic surgery in either the UK or Australia – the reality is that cosmetic surgery is the surgery of want and is almost exclusively funded directly by the consumer.
This poses an ethical dilemma when it comes to training. Who is going to knowingly and willingly pay an inexperienced doctor to perform an invasive surgical procedure that is not medically necessary? And without such opportunities, how can any plastic surgery training scheme claim to deliver clinically competent cosmetic surgeons at the completion of their formal training? They simply cannot and to do so, making such claims is frankly dishonest, unprofessional and highly unethical.
In stark contrast, the nucleus of the surgeons operating in the TCI facilities were amongst the best trained and most experienced cosmetic breast surgeons in the country. They were selected in a highly competitive process and underwent an intensive process of observing, assisting and performing cosmetic breast augmentation. Their teacher was a RACS accredited plastic and reconstructive surgeon. They excelled because they focused on one procedure. They used a well-validated, standardised approach which was customised for each individual patient. One aspect of this standardised approach was the use of round, textured surface, silicone gel filled implants.
Subplot number two. Breast implant associated-anaplastic large cell lymphoma (BIA-ALCL) is a new and rare malignancy that was first reported by Dr John Keech in 1997 [3]. I will discuss this important complication in detail in future blogs but at this stage let us just say that there was a very vested interest in promoting the idea that poor surgical technique, resulting in a chronic biofilm which stimulated a pathogenic immune response was the cause for BIA-ACLC [4]. A lot of money was spent on authors who would promote this fiction and there has been a wonderful exchange of wit and parody as Eric Swanson decimates the academic and professional integrity of key Allergan “mis informants” [5]. We will look at this in detail because there is an obvious elephant in the room. What is the moral liability of those who worked with the implant companies to delay the eventual withdrawal of certain textured implants from the market, Including the ones used by TCI?
But there is more and this is described in the excellent and very brave opinion piece by Patrick Tansley and Daniel Fleming [6]. Both Patrick and Daniel are past Presidents of the Australasian College of Cosmetic Surgery and Medicine and have been very vocal in calling for the recognition of cosmetic surgery as a distinct and separate specialty in Australia (and indeed around the world). Their overriding concern was the lack of independent accountability in Australian research establishments. Their specific concern related to the lack of research integrity demonstrated by members of the surgical research group at Macquarie University in Sydney.
Despite the exposure of the completely flawed hypothesis that BIA-ALCL was the result of poor surgery performed by non-accredited surgeons, this group of plastic and reconstructive surgeons persisted in their attempt to discredit cosmetic surgeons. Using false and misleading data they claimed that patients who had undergone breast augmentation by non-specialist (cosmetic) surgeons were at higher risk of developing BIA-ALCL than patients operated on by RACS-accredited (plastic and reconstructive) surgeons [7]. The authors were eventually persuaded to write a corrigendum, which itself contained flawed data, but otherwise have faced no accountability.
This, then, is the brief introduction to a series of blogs which will look at the dysfunctional state of Australian plastic and reconstructive surgery in the context of clinical dishonesty, lack of research integrity and conflict of interest in cosmetic practice. Australia is not unique in having a poorly regulated cosmetic surgery industry – it is unique though in having, globally, the highest spend per capita on cosmetic procedures.
In conclusion, I should emphasise that the opinions expressed in these blogs are mine and do not represent any official position. I am proud and honoured to have been a plastic surgeon. It is a wonderful specialty that does have a transformational effect on the lives of many people. It is not the same as cosmetic surgery and those who claim otherwise are engaged in a wilful deception of a gullible public. That is fundamentally wrong and responsible members of the media in Australia need the information to hold those engaged in such unethical and unprofessional behaviour to account.
References
[1] https://www.theguardian.com/australia-news/2024/apr/16/the-cosmetic-institute-sydney-class-action-settlement-compensation-heart-problems-seizures
[2] https://www.turnerfreeman.com.au/class-actions/
[3] Miranda RN, Medeiros LJ, Ferrufino-Schmidt MC, Keech JA Jr, Brody GS, de Jong D, Dogan A, Clemens MW. Pioneers of Breast Implant-Associated Anaplastic Large Cell Lymphoma: History from Case Report to Global Recognition. Plast Reconstr Surg. 2019 Mar;143(3S A Review of Breast Implant-Associated Anaplastic Large Cell Lymphoma):7S-14S.
[4] Deva, A.K., Adams Jr, W.P. and Vickery, K., 2013. The role of bacterial biofilms in device-associated infection. Plastic and reconstructive surgery, 132(5), pp.1319-1328
[5] Swanson, E., 2022. Concerns regarding dishonesty in reporting a large study of patients treated with Allergan Biocell breast implants. Annals of Plastic Surgery, 88(6), pp.585-588.
[6] https://www.thepmfajournal.com/education/medico-legal-forum/post/post-truth-bogus-science-cosmetic-surgical-research-concerns-support-the-need-for-research-integrity-watchdog-in-australia
[7] Loch-Wilkinson, A., Beath, K.J., Magnusson, M.R., Cooter, R., Shaw, K., French, J., Vickery, K., Prince, H.M. and Deva, A.K., 2020. Breast implant-associated anaplastic large cell lymphoma in Australia: a longitudinal study of implant and other related risk factors. Aesthetic surgery journal, 40(8), pp.838-846.
