Cosmetic surgery treatment injuries: the New Zealand experience both at home and from cosmetic surgery tourism

Abstract

Objective: This article attempts to understand the number of complications arising in patients returning to New Zealand from cosmetic surgery tourism destinations with reference to the number of patients with complications from cosmetic surgery undertaken in New Zealand.

Methods: Data were requested under the New Zealand Official Information Act 1982 from the Accident Compensation Corporation (ACC) regarding the number of claims for treatment injury following cosmetic surgery undertaken both in New Zealand and overseas for the period 1 July 2014 to 30 June 2019. Also, a prospective audit was conducted of patients admitted to Middlemore Hospital over the one-year period March 2018 to March 2019 for complications arising as a result of cosmetic surgery tourism.

Results: A total of 1048 claims were made to the ACC for treatment injuries arising from cosmetic surgery in New Zealand and from overseas treatment over the five-year period to 30 June 2019. Of these, 738 were accepted by the ACC, with the leading three events being breast reduction/reconstruction, breast implant/augmentation and septorhinoplasty. Bariatric surgery, vein treatment/sclerotherapy, orthodontics and isolated septoplasties were excluded by the ACC as not being ‘cosmetic surgery’. The ACC valued the total cost of treatment of these accepted claims at NZ$6.3 million dollars.

Conclusion: Data outlining the complications arising from cosmetic surgery in New Zealand and overseas indicate a concerning burden of care required for patients who have had cosmetic surgery overseas.

Full text

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Australasian Journal of Plastic Surgery 2020 Volume 3 Number 2
AJOPS | ORIGINAL ARTICLE
PUBLISHED: 30-09-2020
Cosmetic surgery treatment injuries: the New Zealand
experience both at home and from cosmetic surgery tourism
Jonathan Wheeler MBChB FRACS1
AES
1 Middlemore Hospital
Otahuhu
Auckland
NEW ZEALAND
OPEN ACCESS
Correspondence
Name: Jonathan Wheeler
Address: Department of Plastic and Reconstructive Surgery
Middlemore Hospital
100 Hospital Road
Otahuhu
Private Bag 93311
Auckland 1640
NEW ZEALAND
Email: Jonathan.wheeler@middlemore.co.nz
Phone: +64 9 276 0044 Ext: 8755
Citation: Wheeler J. Cosmetic surgery treatment
injuries: the New Zealand experience both at home and
from cosmetic surgery tourism. Australas J Plast Surg.
2020;3(2):40–45. .DOI https://doi.org/10.34239/ajops.v3n2.204
Manuscript received: 23 February 2020
Manuscript accepted for review: 20 April 2020
Manuscript accepted: 18 August 2020
Copyright © 2020. Authors retain their copyright in the
article. This is an open access article distributed under the
Creative Commons Attribution Licence 4.0 which permits
unrestricted use, distribution and reproduction in any
medium, provided the original work is properly cited.
Section: Aesthetic
Topic: Cosmetic surgery
Abstract
Objective: Complications arising from cosmetic
surgery are burdensome for the patient and for the
community. This article attempts to understand
the number of complications arising in patients
returning to New Zealand from cosmetic surgery
tourism destinations with reference to the number of
patients with complications from cosmetic surgery
undertaken in New Zealand.
Methods: Data were requested under the New
Zealand Official Information Act 1982 from the
Accident Compensation Corporation (ACC) regarding
the number of claims for treatment injury following
cosmetic surgery undertaken both in New Zealand
and overseas for the period 1 July 2014 to 30 June
2019. Separate to that request, a prospective audit
was conducted of patients admitted to Middlemore
Hospital over the one-year period 1 March 2018 to 30
March 2019 for complications arising as a result of
cosmetic surgery tourism.
Results: A total of 1048 claims were made to the ACC
for treatment injuries arising from cosmetic surgery
in New Zealand and from overseas treatment over
the five-year period to 30 June 2019. Of these, 738
were accepted by the ACC, with the leading three
events being breast reduction/reconstruction, breast
implant/augmentation and septorhinoplasty. Bariatric
surgery, vein treatment/sclerotherapy, orthodontics
and isolated septoplasties were excluded by the
ACC as not being ‘cosmetic surgery’. The ACC valued
the total cost of treatment of these accepted claims
at NZ$6.3 million dollars. Of all claims with breast
reconstruction cases excluded, 76 patients had their
initial surgery overseas, 620 had their surgery in New
Zealand and 20 were unknown. Furthermore, an
audit at Middlemore Hospital over a one-year period
showed there were nine patients who required in-
hospital treatment for complications arising from
cosmetic surgery performed overseas. Over the

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Australasian Journal of Plastic Surgery 2020 Volume 3 Number 2
Wheeler: Cosmetic surgery treatment injuries: the New Zealand experience both at home and from cosmetic surgery tourism
same time period, a further three patients received
outpatient treatment for complications due to
cosmetic surgery performed overseas.
Conclusion: Data outlining the complications arising
from cosmetic surgery in New Zealand and overseas
indicate a concerning burden of care required for
patients who have had cosmetic surgery overseas.
Keywords: medical tourism, breast implants, plastic
surgery, aesthetics, breast augmentation
Introduction
The denition of a cosmetic procedure varies
between groups. The Accident Compensation
Corporation (ACC) denes breast reconstruction
as a cosmetic procedure,1 while plastic surgeons
would dene it as ‘restoration’.2 The Medical
Council of New Zealand considers breast reduction
a cosmetic procedure,3 despite this procedure being
performed for predominantlyfunctional reasons.4
Consequently there is a signicant cross-over in
denitions of surgery for functional and cosmetic
reasons. This makes it hard to sensibly characterise
the burden of care arising from interventions for
cosmetic reasons. The total number of cosmetic
surgeries performed in New Zealand is hard to
accurately measure due to no reliable reporting
stream.
Surgery for appearance or aesthetic reasons is
expensive. New Zealanders and Australians may
seek this treatment overseas in order to make
signicant savings, but there are risks involved
in travelling overseas for cosmetic surgery. These
include the short initial consultation period,
the risk of venous thromboembolism (VTE), the
dangers of multi-resistant organism infection,
the use of unregulated implants and the lack of
medico-legal recourse for patients who have an
adverse outcome.5 The number of patients who
receive cosmetic surgery overseas is unknown,
and the numbers who have complications arising
from this treatment are not accurately known
either. Literature from overseas studies shows a
measurable cost in the treatment of complications
arising from cosmetic surgery tourism6–8 and
reects the morbidity patients experience from
complications arising from surgery in other
countries.9 Internationally there are concerns
about infectious disease transmission of antibiotic-
resistant bacteria from overseas surgeries.10–12
This article attempts to characterise the number
of complications arising from cosmetic surgery in
New Zealand and in New Zealand-based patients
who have had surgery overseas.
Methods
Information was requested from the ACC in New
Zealand regarding how many treatment injury
claims were received over a ve-year period,
and how many of these resulted from New
Zealand-based procedures versus overseas-based
procedures. Information on the subspecialty of the
initial treating clinician was requested as well as
the types of complications that occurred.
Furthermore, a prospective audit of patients who
had sustained complications from cosmetic surgery
overseas was also conducted at Middlemore
Hospital over a one-year period from 1 March 2018.
Results
The ACC reported a total of 1048 compensation
claims were made over the period 1 July 2014 to
30 June 2019 for complications/treatment injuries
arising from cosmetic surgical procedures dened
by the ACC as being treatment aimed solely at
the ‘aesthetic, cosmetic and wellbeing result’. Of
these 1048 claims, 310 were declined, leaving
738 accepted claims. Figure 1 details the number
of complications by procedure. Figure 2 shows
the type of complication, with infection and
haematoma being most common. Figure 3 shows
the treatment context under which subspecialty the
complication occurred. Just over half had a plastic
and burns surgery context, with the next highest
being general surgery, then appearance medicine
(likely undertaken by GP practitioners) and nally
ear, nose and throat. Figure 4 illustrates that when
breast reconstruction is removed from the data,
most accepted injuries that the ACC agrees to fund
treatment for are for surgeries undertaken in New
Zealand.
The cost of direct treatment over the ve-year
period was NZ$4.4 million, with another NZ$1.7
million for compensation due to loss of earnings
and NZ$0.3 for rehabilitation.

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Australasian Journal of Plastic Surgery 2020 Volume 3 Number 2
Wheeler: Cosmetic surgery treatment injuries: the New Zealand experience both at home and from cosmetic surgery tourism
Fig 4. Claims made by location of initial surgery (breast reconstruction
cases removed)
Fig 2. Treatment injury claims by type of complication from cosmetic
surgery
Fig 3. Treatment complication context, by specialty
Fig 1. Treatment injury claims made to the ACC from 1 July 2014 to 30
June 2019
A prospectively collected database was also
maintained for a year to capture cases admitted to
Middlemore Hospital with complications arising
from cosmetic surgery overseas. Twelve patients
were identied, of whom nine required admission
and surgical intervention. Table 1 details those
cases.
Discussion
Dening what constitutes a purely cosmetic
surgical procedure compared to a reconstructive or
functional procedure is not simple and most plastic
surgery operations are a mix of both. The Medical
Council of New Zealand considers breast reduction
a cosmetic procedure,13 despite this procedure
being performed for predominantly functional
reasons.4 Insurance companies in New Zealand
consider breast restoration following breast
cancer a cosmetic procedure and put articial
restrictions on patients’ ability to claim for certain
procedures. Thus attempts to quantify the number
of complications or treatment injuries arising from
cosmetic surgery procedures is challenging due to
an exact denition. For those operations that are
clearly cosmetic, data are weak to absent as to the
total number of those procedures performed in
New Zealand.
The closest way of objectively understanding the
number of complications from cosmetic surgery
is to request that information from the body
that provides insurance for when unexpected
complications occur. The ACC provides an
automatic no-fault accidental injury compensation
scheme. If a patient has a complication as a result
of surgery and if this is accepted by the ACC as an
unexpected occurrence, the cost of subsequent
treatment and a proportion of lost income are
covered for the patient. A poor cosmetic result
does not reach the threshold for cover under the
ACC. If the ACC has a concern about the care given
to a patient, this will be referred to the relevant

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Australasian Journal of Plastic Surgery 2020 Volume 3 Number 2
Wheeler: Cosmetic surgery treatment injuries: the New Zealand experience both at home and from cosmetic surgery tourism
disciplinary body, but the main focus is on the
patient and their recovery. Consequently, the data
for most patients treated in New Zealand who have
a complication following surgery are captured
by the ACC database. It is more complicated for
patients who have their treatment overseas as
the ACC will accept a treatment injury only if the
surgery has been performed by an appropriately
qualied doctor. However, it is not well understood
by health professionals in New Zealand that the ACC
may cover some patients who have complications
as a result of surgery undertaken overseas and so
it is thought that many patients do not apply to the
ACC to cover their iatrogenic injury. Consequently
the data from the ACC regarding the number of
patients initially receiving treatment overseas may
be under-reported.
ACC data include breast reconstruction and breast
reduction as cosmetic procedures. It is interesting
to note that if breast reconstruction is removed
from the data, there are a third fewer claims to
the ACC for complications arising from ‘cosmetic
surgery’. Breast reconstruction surgery is fully
funded in New Zealand and it is unlikely that
patients would travel overseas to seek this care.
Once breast reconstruction has been removed
from the data, just over 10 per cent of total claims
are for treatment initially performed overseas. The
percentage of cases declined by the ACC was higher
if the surgery had taken place overseas, which most
likely reects either a lack of clear documentation
or the fact that the surgery was performed by a
doctor whose credentials could not be conrmed
by the ACC.
The cases treated through Middlemore Hospital
arising from cosmetic surgery tourism show
complications that are well recognised but could
have been prevented at the time of surgery or
been better managed earlier on. Haematomas
and wound dehiscence were common and should
have been recognised early by the treating surgeon
and managed appropriately. Without knowing
the true number of patients who have surgery
overseas it is hard to determine the incidence or
prevalence of complications arising from cosmetic
surgery tourism. This single hospital receives one
to two cases per month of patients who require
impatient care to manage complications arising
Age Sex Primary surgery Country
of surgery
Complication Management Number of
operations/
interventions
Length
of stay in
days
44 F Abdominoplasty and
thigh lift
Thailand Thigh wound dehiscence Dressings
59 F Bilateral breast reduction,
abdominoplasty, facelift
Thailand Bilateral breast necrosis Skin grafting 2 18
35 F Upper eyelid
blepharoplasty
Korea Exteriorised sutures Refer back to
treating surgeon
49 F Thigh lift and facelift Thailand Thigh wound fat necrosis Debridement
and closure
1 1
50 F Augmentation mastopexy Thailand Infected implants Explanted
implants
1 8
44 F Bilateral breast
augmentation
Thailand Cellulitis IV antibiotics 2
41 F Fat grafting to face Korea Mycobacterium iinfection
—multi-resistant organism
Aspirations 2 1
42 F Arm liposuction Costa Rica Over-resection
69 F Augmentation mastopexy Thailand Haematoma around
implant with subsequent
rupture and pulmonary
embolism
Anticoagulation 1 8
61 F Medial thigh lift Malaysia Thigh wound dehiscence Dressings 3
33 F Bilateral breast
augmentation
Turkey Old haematoma Surgical
washout
1 2
36 F Buccal fat excision Turkey Old haematoma Surgical
washout
1
Table 1: Cosmetic surgery tourism complications treated at Middlemore Hospital, 1 March 2018 to 30 March 2019

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Australasian Journal of Plastic Surgery 2020 Volume 3 Number 2
Wheeler: Cosmetic surgery treatment injuries: the New Zealand experience both at home and from cosmetic surgery tourism
from cosmetic surgery tourism. For some of these
patients, the complication is often present prior to
boarding the return ight home. If these patients
have a signicant infection or dehiscence, they are
taking a signicant risk when they y.
There was one patient in this series with an atypical
mycobacterial infection, and cross-border transfer
of infections is also a critical concern. Patients who
undergo surgery in countries where multi-resistant
organisms are present are at risk of post-surgery
infection with these organisms. Middlemore has
noted an increase in the number of Carbapenem-
resistant organism (CRO) infections from patients
treated in overseas hospitals, which places other
immunologically compromised patients at great
risk.
Three patients in the series had breast augmentation
overseas and subsequent complications. Follow-
up for these patients by the operative overseas
surgeon did not occur. With the risk of anaplastic
large cell lymphoma (ALCL)14 and previous breast
implant concerns, patients who are operated
on overseas should have appropriate follow-up
care. A key issue for ALCL is appropriate consent
for the patient, and overseas surgeons who meet
the patient for the rst time the day prior to the
operation would not meet the expectations of
appropriate consent that exist in Australasia.15
One patient in the series had a pulmonary embolism
(PE). The risk of VTE following major cosmetic
surgery is around one per cent.16 Long-haul ights
compound the risk of VTE17 and consequently
the risk of PE/VTE is high with cosmetic surgery
tourism. Patients should be advised not to y long
haul for at least six weeks prior to and six weeks
after major cosmetic surgery.18
One main weakness of this article is that we do not
know the total of number of patients who travel
overseas for cosmetic surgery and then return to
New Zealand soon afterwards. The other drawback
of this article is the small number of patients that
we can observe through a single hospital. This is
a similar issue that overseas groups nd when
trying to assess the impact of complications arising
from cosmetic surgery tourism on their own health
systems.7,8,10–12 Some articles have attempted meta-
analyses of a number of papers documenting
treated complications but again the numbers are
low and it is hard to assess the true impact.9,19
Furthermore, while we may have some gauge on
the medical complications, there is no literature
assessing patient-reported outcomes or aesthetic
outcomes from cosmetic surgery tourism.
The cost of treating complications arising from
‘cosmetic surgery’ in New Zealand amounts to over
NZ$1 million per year – this is covered by the ACC
levying premiums on businesses in New Zealand.
Patients who choose to have their surgery overseas
do not pay a premium and will be cared for in New
Zealand if they have a complication, but we do not
know the exact number of these patients.
Conclusion
Complications arising from cosmetic surgery are
burdensome for the patient and for the community.
This article characterises the number of known
complications arising from cosmetic surgery in
New Zealand and abroad to the best available
current data.
Disclosure
The authors have no nancial or commercial
conicts of interest to disclose.
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