When is a procedure cosmetic?

Health Secretary Jeremey Hunt was recently quoted as saying cosmetic surgery “purely to improve someone’s looks” should not be available on the NHS and that the decision to fund surgery should be made only if there is a clinical need, such as a mental or physical health risk to the patient. But where do we draw that line?

Sadly, people who don’t understand what cosmetic surgery really is often confuse the term “cosmetic” with “trivial”, but this is far from the truth.

As a consultant plastic surgeon, I have worked both in the NHS and privately. I worked as an NHS consultant until 2001, but as many plastic surgery procedures had already been rationed out of the health service by that time, I went private. Even so I can honestly say, with absolute certainty, that I have never operated on anyone for trivial reasons.

Patients simply don’t walk in and say: “I’m really confident with my body and would just like you to make it even better.” Most patients come in lacking in confidence and feeling self-conscious about their appearance. In some cases their appearance causes them so much distress that they are unable to go out or get a job because they feel so “abnormal”. Our job is to restore them to normality.

There are already strict rules about cosmetic surgery on the NHS. Some of these rationing tools are good, but unfortunately others show less understanding of the problems some patients have. As with all rules, you will have some people who are deservedly the exception and others who will try and bend the rules.

While I don’t condone people who lie or maximise their problems to get operations for free, I do believe there are many worthy cases that do deserve to be treated on the NHS

However, while I don’t condone people who lie or maximise their problems to get operations for free, I do believe there are many worthy cases that do deserve to be treated on the NHS.


This is where defining what constitutes a cosmetic problem is a challenge and the lines become blurred. If a child has prominent ears and is being badly bullied at school by other pupils, is getting an operation to put that right cosmetic or can it stop the mental anguish caused by bullying, which in the vast majority of cases stops?

What about a large, albeit benign, birthmark on someone’s face, which makes them the subject of teasing, but can easily be removed by a face lift-type operation?

Breast asymmetry is another example. For a teenage girl having one breast that is significantly larger than the other can cause a lot of mental anguish, but is this simply a cosmetic concern? By performing a breast enlargement or using an expander in the undeveloped side we could put this right. But will breast enlargement be totally banned on the NHS?

And it’s not just women for whom breasts are an issue. Men can develop breasts as a result of life-saving hormone treatment for prostate cancer. This can cause severe embarrassment. Whether the breasts are removed or not will not help his cancer, but this procedure can make the patient much more able to face the world.


Among the best examples is breast reduction. It is virtually impossible to get this done on the NHS. But in my mind it is not a cosmetic procedure. Many women with excessively large breasts suffer from backache, grooves in their shoulders, rashes and having to endure comments about their chest.

So breast reduction is one of the most rewarding operations done by plastic surgeons. It can restore a woman to good posture, allow her to exercise again, and become much more of a contributor to society, rather than having to visit her GP for painkillers, anti-inflammatories and even anti-depressants. It may be an expensive operation, but it can save the NHS so much money in other treatment that is no longer needed.

I would challenge anyone who thinks this is a cosmetic treatment to take two large bags of flour and put them inside a vest top, securing them at nipple level with a crepe bandage round the neck. Now go shopping or try and lift a small child.  They feel very heavy after a while, but removing 3kgs in weight is not that unusual in a breast reduction operation and that’s usually after the woman has been carrying it around for years.

We have good regulations already to limit the use of aesthetic procedures on the NHS. We train our plastic surgeons for about 18 years to become NHS consultants, surely they are the best people to decide, with their patients, when such operations would benefit the patient and NHS alike.

In the last few years before I retire, it would be lovely to be able to stop defending and justifying my daily work. It really isn’t “trivial” at all, this “cosmetic” work – I prefer “aesthetic”.