Demographics and macroeconomic effects in aesthetic surgery in the UK q

The British Association of Plastic Surgeons (2004) 57, 561 566 Demographics and macroeconomic effects in aesthetic surgery in the UK q C.O. Duncan*, M. Ho-Asjoe, R. Hittinger, H. Nishikawa, N. Waterhouse, B. Coghlan, B. Jones Department of Plastic and Reconstructive Surgery, Wellington Hospital, St Johns Wood, London, UK Received 6 November 2003; accepted 29 March 2004 KEYWORDS Aesthetic surgery; Economic indicators; Training Summary Media interest in aesthetic surgery is substantial and suggestions of demographic changes such as reductions in age or an increase in the number of male patients are common. In spite of this, there is no peer reviewed literature reporting demographics of a contemporary large patient cohort or of the effect of macroeconomic indicators on aesthetic surgery in the UK. In this study, computer records 13 006 patients presenting between 1998 and the first quarter of 2003 at a significant aesthetic surgery centre were analysed for procedures undergone, patient age and sex. Male to female ratios for each procedure were calculated and a comparison was made between unit activity and macroeconomic indicators. The results showed that there has been no significant demographic change in the procedures studied with patient age and male to female ratio remaining constant throughout the period studied for each procedure. Comparison with macroeconomic indicators suggested increasing demand for aesthetic surgery in spite of a global recession. In conclusion, media reports of large scale demographic shifts in aesthetic surgery patients are exaggerated. The stability of unit activity in spite of falling national economic indicators suggested that some units in the UK might be relatively immune to economic vagaries. The implications for training are discussed. Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. In the UK aesthetic surgery forms an integral part of the core syllabus for plastic surgery trainees and is examined in the intercollegiate specialty exam q Presented under the title: Demographics of Patients Undergoing Aesthetic Surgery British Association of Aesthetic Plastic Surgeons Annual Meeting 25 26th Sept 2003. *Corresponding author. Address: Department of Craniofacial Surgery, Birmingham Children s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK. Tel.: þ44-121-3338147; fax: þ44-121- 3338151. E-mail address: cduncan@doctors.org.uk where trainees are required to be able to assess patients, form management plans and be able to discuss surgical techniques. The traditional training forums initially outlined by Nicolle (1983) such as national health service (NHS) lists and ad-hoc arrangements with consultants to attend and assist with aesthetic surgery 1 have been supplemented by some specialist advisory committee (SAC) approved aesthetic fellowships which are few in number and for which competition is intense. Significant changes in NHS aesthetic guidelines S0007-1226/$ - see front matter Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2004.03.003

562 C.O. Duncan et al. have occurred, which have resulted in a decline in the amount of aesthetic surgery performed on NHS lists while public demand has increased. 2 During the same period, the advent of clinical governance and the care standards act (2000) 3 has required hospital chief executives to assume overall responsibility for risk which occurs in their hospital. This means that aesthetic surgery performed by surgeons in private healthcare institutions is subject to the same governance standards as in the NHS. Recent heightened awareness of aesthetic surgery fuelled by increasingly frequent and lurid television and press reports has encouraged the belief that demographic changes such as reducing age, an increase in male patients 4 and increased demand are occurring in the population. Such demand would ideally have to be met by appropriately trained and accredited surgeons. Given the increasing strictures on NHS aesthetic activity, how is aesthetic surgery training to be properly planned and executed? Aesthetic surgery in the United States has been noted to be governed by simple supply/demand economic rules and has also been noted to be sensitive to macroeconomic indicators. 5 The aim of this study was to identify demographic trends in aesthetic surgery patients in a significant provider in the United Kingdom including age, gender and operation type as well as overall changes in surgical volume. At the same time an attempt was made to correlate activity within the unit with macroeconomic indicators to assess whether any procedures were particularly responsive to changes in the economic climate so that an effort could be made to predict training and provision requirements in aesthetic surgery. Materials and methods Permission to access the hospital database was initially sought via the chief executives office and permission for the project was granted by the medical advisory committee of the hospital following which a request for data was co-ordinated by the clinical governance department of the hospital. Computerised hospital records of patients operated on in the plastic surgery department between January 1998 to June 2003 were requested according to fields which included operation date, operation type, patient age and patient gender. No details which could have led to the identification of individual patients were either sought or provided. The data was collated on a Microsoft Excel 2002 spreadsheet on a data protection registered computer. In this study, all operations were counted individually so that if a patient underwent a combination of procedures, each procedure was counted individually. Macroeconomic indicators which were selected for examination and comparison with operative trends included house price, unemployment rates, the London interbank offered rate (LIBOR) and the FTSE 100 index. These were acquired from the office of national statistics, the land registry and FTSE 100 who kindly provided historical data of the FTSE index free of charge on the basis that the purpose was noncommercial research. In order to protect the commercial interests of the hospital where the work was performed, data was expressed as percentage changes compared with figures at the beginning of the data collection timepoint in 1998 and economic variables were expressed similarly to allow trendline comparisons on charts. Results Data of 13 006 patients was analysed. Macroeconomic indicators Analysis of data since 1998 demonstrated stable rises and declines in property values and unemployment, respectively. The FTSE 100 index and LIBOR showed significant variability throughout the period studied with and these changes approximately matched each other. For the purposes of this study, LIBOR was used as a comparison with aesthetic operations. Overall activity and patient age Activity, shown in Fig. 1, showed a slight decline in 1999 followed by a steady rise to the end of 2002. Throughout the period studied, the majority of patients treated were females and this accounted for most of the rise in the overall figures. Male aesthetic surgery patients remained in an almost unchanged minority throughout. The male to female ratio shown in the line chart in Fig. 2 demonstrated a decline of 30% indicating a fall in the proportion of male patients treated between mid 2001 and mid 2003. Analysis of patient age, shown in Fig. 3, indicated that throughout the period studied, the mean age of males was generally lower than that of females but that the difference was not statistically significant

Demographics and macroeconomic effects in aesthetic surgery in the UK 563 Figure 1 Bar chart showing rises in overall activity to 2002 compared with activity in 1998. (P. 0:05; Students t test). The mean ages of patients did not vary significantly throughout the period studied on aggregate or in any operation. Popularity of aesthetic procedures Ten procedures (Table 1) were identified for longitudinal analysis in each of the complete years 1998 2002. Of these, 2 procedures Coleman Fat Transfer and Laser surgery showed significant variability such that their place in the order of popularity changed significantly throughout the 5 year period. Of the remaining eight, facelift and blepharoplasty were consistently the most frequently performed while breast reduction and abdominoplasty were consistently the least frequently performed operations in every year studied. Figure 3 Line chart comparing mean age of male and female patients presenting to the department of plastic surgery between 1998 and 2003. Error bars represent standard deviations. two overall patterns emerged. One group of procedures shown in Figs. 4 6 which included facelift, blepharoplasty, and breast augmentation tended to decline when interest rates were higher and increase when interest rates became lower. Endobrow lift was also associated with some similar changes although these were less obvious. Of these four, this trend was most obvious in breast augmentation. In the remaining procedures, no obvious trend appeared to emerge. Of note, upward trends in these three procedures coincided with interest rate falls commencing late in the third quarter of 2001 in the aftermath of the September 11th tragedy. Comparison with LIBOR When procedure trends were compared with LIBOR, Figure. 2 Line chart showing the ratio of male to female patients between 1998 and the first quarter of 2003. Figure 4 Line chart showing percentage changes in numbers of facelifts performed between 1998 and early 2003 compared with percentage change in LIBOR in the same period.

564 C.O. Duncan et al. Table 1 Showing the popularity in descending order of each procedure analysed in each year 1998 1999 2000 2001 2002 Blepharoplasty Blepharoplasty Blepharoplasty Blepharoplasty Blepharoplasty Facelift Facelift Facelift Facelift Facelift Laser Laser Breast augment Liposuction Liposuction Liposuction Rhinoplasty Liposuction Endobrow lift Rhinoplasty Rhinoplasty Endobrow lift Laser Rhinoplasty Breast augment Endobrow lift Liposuction Rhinoplasty Laser Endobrow lift Breast augment Breast augment Endobrow lift Breast augment Fat transfer Abdominoplasty Abdominoplasty Abdominoplasty Fat transfer Abdominoplasty Breast reduction Breast reduction Breast reduction Abdominoplasty Breast reduction Fat transfer Fat transfer Fat transfer Breast reduction Laser Discussion A significant impetus to perform this study occurred when one consultant plastic surgeon commented to the first author that he had noticed a downturn in his practice since the September 11th atrocity and the subsequent economic changes. The finding that overall activity has shown a consistent increase is, however, not surprising given that a similar trend was identified in the USA between 1997 and 2000 (Rohrich, 2000). 6 In his paper, Rohrich also commented that only 11% of cosmetic surgery patients were males, a figure which is similar to UK numbers according to this study. The fall in male to female ratio may not, therefore, be significant because the overall proportion of male aesthetic surgery patients was so low that small changes in numbers could lead to large changes in ratio, particularly when accompanied by rises in the numbers of female patients. The fact that male patients were on average slightly younger than their female counterparts must be taken in the context that even today, males have a shorter life expectancy than females 7 and that for a given chronological age, males are biologically slightly older than females. Were this to be taken into account, it is likely that male and female ages would have been identical. Otherwise, the absence of any evidence of a decrease in the age of patients seeking any of the procedures studied in the last 5 years suggests that reports of increasingly youthful patients are not representative of unit activity where all the surgeons are accredited. The finding that certain procedures appeared to be inversely proportional to interest rates has never been noted before in the UK although an anecdotal report suggested that a similar trend was identified in the USA in breast augmentation. 8 Krieger (2002) identified that aesthetic surgery practices in the USA are beholden to basic economic tenets of supply and demand in that patients purchased procedures based on competitive pricing. 9 Although Krieger did not identify interest rates as a relevant factor in his paper, the implication that money talks was clear. In a subsequent paper, Krieger Figure 5 Line chart showing percentage changes in numbers of blepharoplasty s performed between 1998 and early 2003 compared with percentage change in LIBOR in the same period. Figure 6 Line chart showing percentage changes in numbers of breast augmentations performed between 1998 and early 2003 compared with percentage change in LIBOR in the same period.

Demographics and macroeconomic effects in aesthetic surgery in the UK 565 (2002) outlined the way in which a fall in interest rates is intended to cushion the economy and support consumer confidence in times of recession (5) such that purveyors of luxury or expensive goods need not suffer loss. The drop in interest rates in the last quarter of 2000 may have been related to the sustained rise in aesthetic surgery procedures noted in this study in that credit became inexpensive during this time. The provider in question did not provide a credit method for payments and, therefore, it was not possible to identify trends with regard to patients use of credit schemes to fund their surgery although Orton (2002) noted that such a trend does exist. This would be a useful avenue for future research. One criticism of this study is that a surgeon or small group of surgeons with similar and large individual practices might be sufficient to skew the repertoire of procedures within the unit away from what would be typical. In this study, all cases coded under plastic surgery were included in the data search. This represented the activity of a total of 51 surgeons who currently have admitting rights to this hospital and comprises of a very broad range of aesthetic practice. It is, therefore, likely that the case mix studied represented a realistic snapshot of UK aesthetic practice in the period 1998 2003. The consistency of the popularity of eight of the procedures (excluding laser and fat transfer) shown in Table 1 provides a useful index to requests which new plastic surgeons are likely to face. In this respect, UK patients were similar to their US counterparts (Rohrich, 2000) in that blepharoplasty, facelift and liposuction occupied places in the top five procedures in each year with breast augmentation occupying a top six place in all years. Abdominoplasty was not found to be especially popular and this may reflect the fact that it is still provided according to some NHS aesthetic guidelines. Coleman Fat Transfer, which showed the biggest increase in popularity might have indicated responsiveness of the public and surgeons to a new procedure. Sidney Colemans technique first published in 1995 10 and presented for facial liposculpture in 1997 11 was first performed in the department in 1997 and increased in popularity each year thereafter and was, therefore, unrelated to any macroeconomic change. Laser resurfacing which showed the biggest decrease in popularity may have owed its demise to internal restructuring of the laser service at the hospital at the time of the study, however, it is noteworthy that Rohrich (2000) identified the same trend in the USA and it may be that laser resurfacing is becoming less popular with patients and surgeons. A final useful by product of the consistency patterns noted in this study is that it provides a basis for teaching programmes within rotations and examinations based on the likelihood of a surgeon having to perform each type of procedure. The data which has been presented has medicolegal and governance implications for any newly accredited surgeon commencing in aesthetic practice. NHS aesthetic guidelines are now sufficiently tight that many trainees can only expect to have performed significant numbers of the two least popular procedures identified in this study during their training and even these two procedures are likely to become scarcer in the future. A recently trained plastic surgeon requesting admission rights to a private healthcare provider must be able to demonstrate that they meet that providers requirements vis a vis training so that they do not pose a risk to their patients, themselves or the hospital. Typically, this requires the surgeon to be on the specialist register and to have their nomination supported by a certain number of surgeons in the hospital prior to appointment by the medical advisory committee of the hospital. The department of health has been advised that surgeons should then expect to be subject to the same revalidation and appraisal procedures as occur in the NHS (Orton, 2002) and to adhere to the principles of good medical practice. 12 With only 12 SAC approved aesthetic fellowships available in the UK per annum, it is likely that a shortfall in UK trained aesthetic surgeons will occur over time. If the gradual rise in demand noted in this study is sustained, then the question arises of who is going to treat these patients and what level of training will they have? Wanzel and Fish (2003) suggested that aesthetic surgery should comprise 12.2% of a plastic surgery training programme, 13 equivalent to 9 months of a 6 year programme, however, it is unlikely that this figure is currently being met in the UK. Surgeons from related specialties are unlikely to have had any more accredited aesthetic training than their plastic surgery counterparts and two possibilities present themselves. Either plastic surgeons from the European Union whose accreditation in their country of origin permits admission to the specialist register in the UK may attempt to meet the demand, or the public continues to fall prey to unaccredited surgeons in unregulated clinics until the national commission monitoring standards begins to bite. Neither option is appetising and the solution has to be to establish sufficient approved aesthetic surgery training posts such that all plastic surgery trainees receive the requisite hands on experience to be able to meet the rising public demand. There was no evidence of decreasing age in the patient cohort studied, and men if anything became

566 C.O. Duncan et al. more reticent about seeking aesthetic surgery. Demand increased year on year in spite of unstable economic conditions and some operations including breast augmentation, facelift and blepharoplasty appeared to change in frequency according to indicators such as interest rate. Operation popularity remained constant between 1998 and 2002 in this provider, and the majority of popular procedures fell outside NHS aesthetic guidelines. Finally, this survey makes a case for an increased number of approved aesthetic training posts. Acknowledgements I would like to acknowledge the office of National Statistics, FTSE 100, and the Land Registry. References 1. Nicolle FV. Problems of aesthetic plastic surgery training within the National Health Service. Aesthetic Plast Surg 1983;7. 2. Orton C. Regulating cosmetic surgery. BMJ 2002;324:1229. 3. Care Standards Act 2000. The Stationary Office London, 2000. 4. Fabrizio T. Changing times in cosmetic surgery. Recession hits the market in plastic surgery. Nord Med 1992;107:57. 5. Krieger LM. Cosmetic surgery in times of recession: macroeconomics for plastic surgeons. Plast Reconstr Surg 2002; 110(5):1347. 6. Rohrich RJ. The increasing popularity of cosmetic surgery procedures: a look at statistics in plastic surgery. Plast Reconstr Surg 2000;106(6):1363. 7. Life Expectancy at Birth. National Statistics, London. Press Release 21st August; 2003. 8. B Jones. Personal communication; 2002. 9. Krieger LM. Discount cosmetic surgery: industry trends and strategies for success. Plast Reconstr Surg 2002;110(2):614. 10. Coleman SR. Longterm survival of fat transplants: controlled demonstrations. Aesthetic Plast Surg 1995;19(5):421. 11. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg 1997;24(2):347. 12. Good Medical Practice in Cosmetic Surgery. London: Independent Healthcare Association; May 2003. 13. Wanzel KR, Fish JS. Residency training in plastic surgery: a survey of educational goals. Plast Reconstr Surg 2003; 112(3):723.