I have written two series of blogs in the past which spanned many weeks and covered the complex mix of fact, opinion and medico-legal deviance in two major cases of unexpected death in cosmetic practice in Hong Kong.
Perceptions and Deceptions related to the death of a 24-year-old girl who died after a catastrophic failure of medical care in a cosmetic clinic. The proposed procedure was a bilateral breast augmentation, but her brain was destroyed before the knife touched the skin. 'Death by Misadventure' was the official result of the inquest but a very brief review of the evidence revealed dishonesty, lies and corruption in both the medical and legal professions.
The second series, Gross Negligence Manslaughter in Healthcare: The Medico-legal dilemma, related to a conviction of gross negligence manslaughter following a very strange postoperative death after a cosmetic liposuction. This case really brought to light the problems of cosmetic surgery in Hong Kong where there is no formal specialty. Claims that the plastic surgery training led to competency in cosmetic surgery were so far from the truth that I was compelled to alert the Medical Council of Hong Kong (MCHK) to the perjury of a prosecution medical expert when giving evidence under oath.
The MCHK is in a very difficult position, and I do not have high hopes that they will appreciate how egregious it is to lie under oath in a criminal case that resulted in a doctor receiving a six-year prison sentence. Of note, the recommended sentence for perjury is up to eight years!
So, now to Australia! I really do not want to write a long and detailed series of blogs about the multiple concerns in this turf war between the board-certified plastic and reconstructive surgeons and the 'non-accredited' cosmetic surgeons. What I can do is identify some of the key players and then leave it to the Fourth Estate in Australia to 'do the needful', if they are so inclined.
First, let me share some observations made by others. Patrick Tansley and Daniel Fleming have written a very detailed and comprehensive account of research dishonesty in Macquarie University, Sydney. They identified associate Professor Mark Magnusson and Professor Anand Deva as senior plastic and reconstructive surgeons who used false and misleading data to promote their elitist agenda [1].
There is no doubt that the average reader would find Patrick and Daniel's article 'heavy going', but a good investigative journalist should be able to dissect the meat from the stew and present the stark reality to an informed public.
Prof Anand Deva is perhaps the most controversial figure in Australian plastic surgery at this time. His dishonest research and conflict of interest issue have been forensically exposed by Dr Eric Swanson, an American breast surgeon. The series of editorials written by Swanson are a masterpiece of academic rigour and debate and Deva’s attempted responses are cringe worthy in their ineptitude. I will just reference one editorial and one response but a study of the comments, facts and opinions regarding the safety of textured breast prostheses should be required reading for all plastic surgery trainees [2,3]!
Reading Deva’s response to the very legitimate criticism of his '14-point plan' is a revelation of a very conflicted person trying to be smart and failing miserably. The now completely discredited 14-point plan was an attempt to standardise surgical technique in order to reduce / eliminate capsular contracture and breast-implant associated, anaplastic large cell lymphoma following cosmetic breast augmentation. The fundamentally flawed hypothesis was that these conditions were surgeon-related and independent of implant type. I quote one passage here which sounds like the ultimate academic projection (I use this term in the current political sense where a person attributes their own failings to others):
“I have attempted to bring the debate back to solid ground and hope that it has been enough to bring both Dr Swanson and any other skeptical readers to a point of greater understanding and awareness. However, I never presume to be able to convince everyone with facts, logic, and evidence. I respect the right for individuals to hold a contrary opinion and enjoy the process of scientific debate. At some point, however, one should recognize that further engagement with closed minds that are intent on pushing their own ideas from a position of limited understanding is a waste of time and energy. For those of us who believe that improving outcomes through good practice, evidence, and research, I welcome you all to join us in trying to move aesthetics to where it should be—an outcome-driven profession based on science, objective evaluation with the patient, and his/her well being placed at front and center. For those who are like-minded and have taken the pledge, let us continue to build on an evidence base to improve outcomes in breast implant surgery for the sake of our patients.”
The "pledge" referred to in the last sentence is to affirm the use of the 14-point plan. There are so many things wrong with this statement not the least is that Deva has manipulated and falsely distorted evidence that actually increased the risk of adverse outcomes in cosmetic breast augmentation. The full article is available as a .PDF from Oxford University Press. Aspiring academic breast surgeons should read this and other related articles to learn what NOT to do in academic publishing.
So, these are two completely independent sources of concern and I add my own experience which is in the context of the 'TCI case' referred to in the previous blog. The three (plastic surgery) medical experts for the plaintiffs were Professor Anand Deva, Professor Mark Ashton and Dr Rohit Kumar. All three claimed, quite falsely, that (in Australia) the training in plastic and reconstructive surgery was the only way of achieving competency in cosmetic breast surgery. This is simply not true and the Australian public need to be protected from such misinformation. Of course, it is part of the syllabus of the Royal Australian College of Surgeons accredited training programme but there is no way that operative competency can be achieved within such a programme.
I should mention that this is not a peculiarly Australian problem and we just have not addressed the ethical and professional problem of how to train a person to perform surgery where the client pays for the procedure. How do you obtain a valid consent when you perform your first independent cosmetic procedure? The moral dilemma concerns the purchase of a service from a named practitioner. It is just not appropriate for that person to then allow an untrained person to perform the procedure on their behalf. This problem does need more discussion.
Just to reinforce the previous comment that Prof Deva is the most controversial plastic surgeon in Australia, I have to add my own observation; that I was shocked by his dishonesty when providing an expert opinion on the first index case in the TCI class action. He used a photograph of a patient taken two years after a cosmetic breast augmentation and claimed that it was a postoperative photograph. The problem was that in the intervening period the patient had become pregnant and had breast fed for a period. This was not an 'honest mistake' as determined from the context of the report. There were genuine postoperative photographs provided by the patient before her pregnancy which showed a very acceptable result. I have no idea whether my observation of this misleading error had an impact but the patient was removed as the index case and replaced by another.
This second patient claimed to have suffered a postoperative haematoma that resulted in a contracture. Deva reviewed the case many years after the procedure and described a classical presentation of a heamatoma in his report. Was this the result of misleading details given by the patient or just poor history taking? The problem was that the signs and symptoms were not described in the contemporaneous medical or nursing records. This dishonesty is shocking; such behavior is clearly unprofessional and should / must be taken up by the regulatory authorities in Australia. The question is whether the regulatory authorities in Australia are fit for purpose? I have shared my professional opinion. It is however, for professionals and the media in Australia to 'do the needful' (there I have said it again! This was the typical referral letter when I was training forty years ago in the UK: “This patient has a *****. Please see and do the needful!”).
I do not propose to continue with these blogs proactively but will continue reactively if there are any questions or further opinions expressed. I will be posting this on LinkedIn and would welcome any response, particularly from Anand Deva who appears to be the most conflicted senior plastic surgeon in Australia at this time.
References
2. Swanson E. Concerns regarding dishonesty in reporting a large study of patients treated with Allergan Biocell breast implants. Annals of Plastic Surgery 2022;88(6):585–8.
3. Deva AK. Response to “Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL): why the search for an infectious etiology may be irrelevant”. Aesthetic Surgery Journal 2017;37(9):NP122–8.
