Andrew Burd: What is cosmetic surgery?

Following on from the recent local discussion about safety in the cosmetic surgical community in Hong Kong I have been asked to give a talk on “Cosmetic Surgery Trends and Developments” in a meeting organized by our local medical association. I must admit that I have spent a considerable amount of time over the years considering the word “cosmetic” and putting this into some sort of context. My first realization about the sensitivity of the term was overhearing the heated theatre coffee room conversations of my seniors talking about territory, training, cowboys, etc. That was some 30 years ago, and nothing much has changed. The mainstream plastic surgical professional association, when I was training, was the British Association of Plastic Surgeons (BAPS).

It was formed in 1946 and attracted some bright and brilliant people, but the training in the NHS was highly competitive. As a consequence of the bottleneck in training, a significant number of very experienced and competent middle grade plastic surgical trainees had to find alternative careers. In the 1980s the British Association of Cosmetic Surgeons was formed. The requirements for membership were to have the old style generic Fellowship of the Royal College of Surgeons (FRCS) and to have spent two years in cosmetic surgical practice. BAPS and BACS did not see eye to eye, and out of the conflict a third party emerged; the British Association of Aesthetic Plastic Surgeons (BAAPS). I must admit that I found this all very confusing then, and still do now, so I do not like to imagine what the clients/patients think. The only difference I could perceive between BAPS and BAAPS was the length of the vowel sound in the acronym, and my only association for that was socioeconomic status. I am sure you remember that Neil Tweedie comment about coal being delivered to Buckingham Palace in sex.

I did recall that there was some legal dispute with BACS some 20 years ago, but it seems quite established now, and the current president, Edward Latimer-Sayer, has a “no-nonsense approach” to cosmetic surgery that he develops well on his personal website.

But on this occasion it is not the cosmetic/aesthetic confusion that I am considering; it is another semantic challenge: what is the difference between a surgeon and a doctor? What is the difference between surgery and medicine? Indeed to add to the confusion of the poor British patient who wants a little positive “cosmetic” enhancement I find there is a British Association of Cosmetic Doctors (BACD).

On a side note with regard to acronyms, I applaud the honesty of the dermatologists, and before anyone misinterprets what I am about to say, my little brother is a dermatologist, and I love him dearly as a person but also have the greatest respect for who he is and what he does in his professional life. The no-nonsense British Association of Dermatologists refer to themselves as BAD.

My friend Ming Teoh, who is the head of medical services (Asia) for the Medical Protection Society (MPS), is hedging his bets; he speaks after me next week, and his talk is entitled “Is safe cosmetic practice possible?” Actually I have always had problems when people refer to medical or surgical “practice.”  Why not just go ahead and do the real thing? But back to surgery. What is surgery? I have a colleague who is not only a fully qualified plastic surgeon but is also a trained solicitor and barrister.  If I ever want a complex answer to a simple question I will ask David Wong.

And so I did this morning; “David, how would you define the term ‘surgery’?” The discussion continued in the background throughout the morning rounds but was essentially inconclusive. There is no Legal, legal definition and looking at one legal definition did not inspire confidence, I quote: “Surgery, med.jur. That part of the healing art which relates to external diseases; their treatment; and, specially, to the manual operations adopted for their cure. Every lawyer should have some acquaintance with surgery; his knowledge on this subject will be found useful in cases of homicide and wounds.

I am not sure I like the linking of surgery and homicide! But the search continues and again from the web we find the following definition:
“Surgery\Sur”ge*ry\,noun [OE.surgenrie, surgerie;cf.OF.cirurgie,F.chirurgie, L.chirurgia, Gr.?. See{Surgeon}.] The art of healing by manual operation; that branch of medical science which treats of manual operations for the healing of diseases or injuries of the body; that branch of medical science which has for its object the cure of local injuries or diseases, as wounds or fractures, tumors, etc., whether by manual operation or by medicines and constitutional treatment.”

Now this is looking more interesting as the term “by manual operation or by medicines and constitutional treatment” is so gloriously vague that it suggests that surgery is medicine and medicine is surgery. I obviously have a lot of work to do before next Friday’s seminar and will report back in due course. Before I return to the books I should mention another plastic surgery related acronym, BAPRAS. This stands for the British Association of Plastic Reconstructive and Aesthetic Surgeons. BAPRAS claims to be the “Voice of Plastic Surgery,” but more of that later.

Andrew Burd is professor of plastic, reconstructive and aesthetic surgery at the Chinese University of Hong Kong. His major clinical interests involve paediatric burns care and the role of plastic surgery in the palliation of advanced malignancy. Academic interests include pragmatic ethics related to the practice of medicine including research and publication.