The search for integrity in the cosmetic surgery market

The death of a Toronto woman from complications following liposuction has prompted Ontario to undertake a wholesale review of the regulation of cosmetic and aesthetic surgery, and sparked a national debate over which physicians should be allowed to perform invasive procedures.

In September, 32-year-old real estate agent Krista Stryland died following liposuction performed by Dr. Behnaz Yazdanfar of the Toronto Cosmetic Clinic. Yazdanfar is a family physician with no formal surgical training who claims on her website to perform a wide range of invasive procedures, including breast surgery, liposuction and tummy tucks.

In the aftermath of Stryland's death, it was revealed that the College of Physicians and Surgeons of Ontario has failed to act after struggling for years with the issue of cosmetic surgery performed by physicians with no formal surgical training.

College President Dr. Preston Zuliani acknowledged that more could have been done to deal with the issue of unqualified physicians performing cosmetic procedures. The college is now fully committed to a plan of action that ensures only qualified plastic surgeons can perform such invasive procedures.

“In retrospect, might we have been more aggressive, earlier?” Zuliani inquires. “Yes, that's a fair statement. But I think we're making up for it now. We consider this to be a very important issue of public safety and public trust.”

Following Stryland's death, the college canvassed the more than 2400 members to determine the extent to which doctors may have expanded their practices to include cosmetic and aesthetic procedures without having obtained appropriate training. It is believed several hundred doctors, mostly family physicians, have been advertising themselves as “cosmetic surgeons,” but have not been telling patients they are not formally qualified to perform surgery.

By late December 2007, the college had notified 16 physicians that they are being investigated to determine if they are qualified to offer these medical services. Some 20 others who haven't answered a college questionnaire about their qualifications had until the end of 2007 to respond or their licenses could be suspended.

The college has declined to identify the physicians, or indicate whether they have been asked to cease all invasive cosmetic procedures, until the investigation is completed.

A college committee of experts is also drafting recommended changes to provincial legislation that would expand the association's regulatory authority and ability to shut down facilities that do not meet basic medical standards.

Plastic surgeons, who have long lobbied provincial colleges to impose restrictions on physicians advertising themselves as cosmetic surgeons, applauded the efforts but lamented the fact that cosmetic surgery remains unregulated in most Canadian provinces.

Dr. David Kester, president of the Canadian Society for Aesthetic Plastic Surgery, said only British Columbia and Alberta now regulate cosmetic procedures. The former initiated a rigorous regime in the early 1990s to rein in a growing number of private surgical clinics.

In Ontario, however, Kester says a family physician only needs to notify the provincial college that they are changing the scope of their practice and then meet with a mentor who assesses their ability to perform the new procedures. Most plastic surgeons consider that an inadequate assessment of ability to perform complex, invasive procedures, he adds.

Dr. Gordon Wilkes, president of the Canadian Society of Plastic Surgeons, says most so-called “cosmetic surgery” procedures are actually extensions of complex reconstructive surgery that plastic surgeons train for years to perfect. Despite this, aggressive advertising by cosmetic surgeons attempts to convince prospective patients that procedures are simple and risk free.

“There is no integrity in the marketplace,” Wilkes says. “The public confuses cosmetic surgery with plastic surgery. And the term cosmetic surgery is thrown around a lot despite the fact it is not a term that has a lot of integrity for licensing and accreditation bodies.”

Zuliani notes 1 problem is that most provincial colleges are created by provincial legislatures, which are primarily interested in the regulation of insured medical procedures performed in public facilities.

Kester says many people within the medical establishment have long considered cosmetic procedures to be unworthy of regulation, only to be forced to confront the issue after a patient dies unnecessarily. Others cast the dispute as a “turf war” and reject arguments that only plastic surgeons should perform cosmetic surgery.

“It's always been a trivialized area of medicine, and not thought of as real surgery,” says Kester. “That attitude has contributed to this problem. The fact is, a tummy tuck is every bit as stressful and risky as having your uterus removed. It's a 2 to 3 hour procedure with all of the complications of major surgery.”