Re: Reply to Letter by Varma P, Kiely J, Giblin AV. Cosmetic tourism during the COVID-19 pandemic: Dealing with the aftermath by McCrossan S and Jivan S

Abstract

Dear Sir We read with interest the reply to our letter about specific cases of cosmetic tourism treated during the pandemic at Pinderfields Hospital in Wakefield, UK. 1 , 2 This highlights our concern that we are likely to see an increase in such cases, especially as cosmetic surgery tourism evolves. As discussed, this patient group is particularly vulnerable and as Plastic Surgeons we should advocate on their behalf regarding the potential risks they are exposed to. By travelling abroad for surgery, there is no guarantee that patients will undergo the same rigorous preoperative investigations as in the UK e.g. anaesthetic assessment and MRSA screening. Anecdotally we have also found a high prevalence of multiresistant bacterial infection, which should be taken in to account when providing treatment. Furthermore, the risk of air travel in the postoperative period is something that should not be taken lightly. These patients are in a state of increased oxygen consumption due to the trauma of surgery and resulting increased adrenergic outflow. 3 The effect of low pressures on an aeroplane and reduced oxygen availability may be detrimental in the recovery process, as well as the increased thromboembolic risk and subsequent complications which may occur. The concept of a holiday combined with an operation is appealing to patients, especially if travel involves visiting a hot and sunny country. Case 2 in the reply by McCrossan and Jivan looks at a patient who had an abdominoplasty in Pakistan and presented with wound dehiscence and cellulitis. His wounds have consequently become hyperpigmented and have hypertrophic scarring. There is evidence that ultraviolent B (UVB) radiation impairs skin wound healing by affecting focal adhesion dynamics. 4 This could partly explain the poor wound healing and hyperpigmentation in this patient. As clinicians, we have a duty to protect patients from unsafe surgical practices. Both our papers highlight the danger of inadequate follow up. In the letter by McCrossan and Jivan, the patient in case 3 is sent back from Iran after a major procedure of a 360° liposuction, ‘Brazilian butt lift’ and revision abdominoplasty with drains in situ. She represented with an infection and required hospital admission. Furthermore, in our cohort of patients that presented during the pandemic, one patient flew back to the UK from Turkey one day post transfusion of 4 units of red blood cells. Regulation of international practices is a difficult problem to tackle. In our previous letter, we had mentioned that it may be prudent for these patients to have additional insurance if they undertake cosmetic procedures abroad but this would be difficult to enforce. Another suggestion from the British Association of Aesthetic Plastic Surgeons (BAAPS) has been for hospitals in the NHS to invoice foreign providers with the costs of treating complications. 5 In the UK, the RCS Cosmetic Surgery certification is a scheme which will provide accreditation for key competencies demonstrating expertise to patients, which aims to make the cosmetic surgery industry safer. 6 This is an excellent example of how we can help to regulate practices and keep patients safe. We hope this will inspire other countries to follow in similar footsteps. Funding Not applicable Ethical approval Not required Conflicting interests The author(s) declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article