Liposuction continues to be the number one cosmetic surgical procedure performed world wide. This is a great tribute to Prof Yves-Gerard Illouz, who pioneered the use of suction assisted lipolysis, using blunt cannulae after tissue infiltration. The basic principles are very simple but the practice is fraught with traps for the unwary. Patient selection and preparation are essential pre-requisites for a succesful procedure. There is a broad consensus that there are variations in risk which relate to the general state of health of the patient, the amount of fat to be removed, the anatomical regions to be treated and the form of anaesthesia used. In addition, the combination of tumescent liposuction and other cosmetic procedures increases the risk of adverse events. One area of controversy is the safe upper limit of local anaesthetic to be used. The American Academy of Dermatologists published guidelines that indicate a maximum safe dose of 55mg of lignocaine/kg bodyweight. This is much greater than the 7mg of lignocaine (with adrenaline) recommended for nerve blocks and local infiltration. The American Society of Plastic and Surgeons approved the National Guideline Clearing House recommendation of 35mg/kg with some reservations. Despite the guidelines and recommendations, complications and deaths do still occur. One of the vexed questions facing regulating authorities is what to advise when the specialists do not agree. This really does underline the need for training in the whole package of care. This does take some time and requires far more than a weekend workshop!

Tragically, in June 2014 a thirty-two-year-old lady died after undergoing a liposuction procedure in a private clinic in Hong Kong. An investigation is underway but that does not stop the ‘experts’ from giving their opinions to the press who, in turn, report with little understanding of the medical poltics involved. Quite frankly, we have no experts, or should I say ‘specialists’, in cosmetic surgery in Hong Kong. There are some extremely good cosmetic surgeons but there is no specialty of Cosmetic Surgery. So there is a fight for ‘turf’, and as in other parts of the world, the fight is unfair and based on highly flawed arguements. Some local plastic surgical specialists claim that they are the only ones ‘trained’ in cosmetic surgery. This belies the fact that in Hong Kong, training only occurs in the public sector hospitals, where no cosmetic surgery is performed.

I find it ironic that some of the registered specialists in Plastic Surgery in Hong Kong have been neither trained nor assessed in their competance in plastic surgery. Their specialist status is due to a grandfather clause, a back door, in the Hong Kong Academy of Medicine Ordinance which was enacted in 1992. Bylaw 16 was repealed in 1998 and is not mentioned these days! Medical politics. Meanwhile, doctors who have not had specialist training in the public sector are performing cosmetic interventions. Most have created their own training portfolios and most practice at a very high standard. There is a group, for whom I have high respect, who have responded to the recent death in a private clinic in what I would call a pro-active way, a responsible way, a mature way. They are meeting to develop their own consensus guidelines for the provision of safe and effective treatment for a range of procedures they currently undertake. I am sure that it would be possible to reduce this situation to a mathematical formula or a Venn diagram. A plastic surgeon may be, but is not necesarily, a cosmetic surgeon; a cosmetic surgeon may be, but is not necessarily, a plastic surgeon. Another complicating factor is that a specialist in plastic surgery in country A may not be the same as a specialist in plastic surgery in country B. We (the professionals) know that but what about the patients? Looking at Hong Kong again, for historical reasons, plastic surgeons do not deal with hand surgery, acute or elective, or lower limb trauma. Both are dealt with by the orthopaedic surgeons.

In another lifetime (1988) I was awarded the Kay-Kilner Essay Prize by the British Association of Plastic Surgeons for an essay titled ‘Superspecialisation Leads to Higher Surgical Standards’. Suffice to say I agreed with some reservation. I am one of the fading generation of plastic surgeons who undertook a comprehensive training in the generality of surgery before specialising in plastic surgery. I do think that broad base leads to a surgeon who has more reserves to draw on if per-operative complications arise. Superspecialisation is good for the mature surgeon. I would simply not recommend specialising too soon. But here are a few provocative questions to leave with you: Is cosmetic surgery a super / sub specialty of plastic surgery or a specialty in its own right? I used to think the former now I think the latter. So where are the cosmetic surgery specialists going to receive their training? Who is going to train them and who is going to assess their competence? Answers, please, on a postcard to…

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Andrew Burd (Prof)

The Chinese University of Hong Kong.

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