A SYSTEMATIC REVIEW ON COMPLICATIONS OF
COSMETIC SURGERY AND ETHICAL CONCERNS .
Sathiya B 1 , Divya D 2 ,and Gandhimathi S N S 3
1,2
3
School of Advanced Sciences,Vellore Institute of Technology,Vellore,India.
School of Social Sciences and Languages,Vellore Institute of Technology ,Vellore ,India.
1
sathiya.b2024@vitstudent.ac.in
2
divya.d2024@vitstudent.ac.in
3
gandhimathi.sns@vit.ac.in
Abstract
Over the years there has been a growing trend in the popularity of surgery fueled by advancements in
technology and an increasing societal focus on appearance. This rise in interest brings with it medical
challenges and ethical dilemmas that deserve careful examination. This review explores the
complications linked to surgery such as infections, hematomas, nerve damage, blood clots, scarring
and issues related to anaesthesia. It also addresses concerns, regarding consent, advertising and
misleading the public patient autonomy versus non maleficence economic and social pressures and
the vulnerability of patients. Moreover, the reviews frameworks in different countries highlighting
both the similarities in ensuring patient safety and upholding ethical standards. By analysing academic
studies this paper seeks to navigate the complexities surrounding surgery. It advocates for the
establishment of regulations and more stringent ethical guidelines to prioritize patient well-being and
to prevent the advantages of procedures from being overshadowed by potential risks and ethical
dilemmas.
Keywords
Cosmetic surgery , complications, ethical concerns, psychological impacts
Introduction
Cosmetic surgery, which covers many procedures to enhance physical looks, has gained popularity in
recent years. This trend stems from better surgical methods less invasive options, and society's
growing focus on beauty ideals. People often seek facelifts, breast enhancements fat removal, and
nose jobs to boost their confidence and improve how they see their bodies. Yet, the path to looking
better has its own hurdles and dangers(Plastic Surgery.org).
While cosmetic surgery has its upsides, it also carries risks that can cause serious health issues. These
problems range from small ones like scars to bigger concerns such as infections, blood clots, nerve
harm, and issues with anaesthesia. The growing number of surgeries each year shows how crucial it is
to understand these risks, both for patients and doctors.
Besides health issues cosmetic surgery also brings up ethical questions. Informed consent, a key part
of ethical medical care often gets overlooked in the rush to please patients and make money.
Misleading ads and wrong ideas can warp what patients expect leading to unhappiness and regret.
Surgeons face a tough ethical choice in balancing patient wishes with the duty to avoid harm
(Cleveland Clinic).
Methodology
The methodology for this systematic review on complications of cosmetic surgery and ethical
concerns will begin by identifying key research questions, focusing on common complications and
ethical issues in cosmetic procedures, with attention to global differences. Studies eligible for
inclusion will involve quantitative (e.g., clinical trials, observational studies) and qualitative (e.g.,
ethical discussions, interviews) research, as well as international medical reports. A comprehensive
search will be conducted across databases such as PubMed, Embase, and grey literature sources like
WHO reports, using a predefined set of keywords related to cosmetic surgery complications and
ethical concerns, including a global scope.
1. Medical Complications of Cosmetic Surgery
1.1. Infections
Infections are an issue following procedures and can vary in severity based on the specific type of
surgery undertaken; common infection locations include the surgical area as well, as the chest and
lungs where bacteria or other microorganisms may cause infections ranging from mild, to severe
outcomes. Infections that occur at sites are quite common. Can be caused by different factors like
using unsterile surgical tools or contamination during the surgery process as well, as inadequate care
after the operation is done. All medical staff should ensure a hygienic environment during surgeries
to prevent these infections. It’s important to note that symptoms of these infections may include
redness around the wound area, painful sensations and the release of fluid, from the site
where surgery occurred. If these infections are not treated promptly. Effectively there is a risk of them
becoming more serious which could result in conditions, like abscess formation or wound reopening
(known as wound dehiscence). Severe surgical site infections (SSIs) may cause symptoms such as fever
and chills along with a feeling of unwellness which could indicate the start of sepsis – a critical
condition necessitating urgent medical attention (Healthline).
1.2. Hematomas and Seromas
After a surgery or injury, there may be a buildup of fluid close to the surgical site, which is termed as
hematoma or seroma. However, these two terms are not interchangeable, as they differ in
composition and risk of complications.
Hematomas are ruptures of the vascular wall with the consequent formation of blood collections
outside the blood vessels. The mechanism of action is blood leaking from a damaged vessel into the
surrounding tissues. Hematomas typically look like bruises, although they can be more massive and
more painful which leads to the development of discomfort, swelling, even sometimes, infection. In
the most severe situations, surgical drainage may be needed to avoid more complicated complications
in the future.
Seroma, which is the other type, includes the clear watery substance and it is produced by the body
itself, also called as serous fluid. The resulting lump(s) tend to be soft and contain the accumulated
fluid near the surgery site. Hematomas are generally less severe than seromas but they can still
provoke some degree of the symptomatology, and thus, slower healing. On the other hand, some cases
of the formation of the seromas can be associated with their infection or in some cases, needle
drainage is recommended. Usually, they are re-absorbed even without special treatment.
1.3. Nerve Damage
Nerve damage, one of the most critical complications suffered in plastic surgery, can be a very big
problem. When the nerves are damaged, the patient develops a loss of sensation, tingling, weakness,
or even paralysis. The effects can be very threatening to the patient and sometimes may become
permanent.
The ethical dilemma rises when the nerve damage is on a patient due to the surgical trauma or
inappropriate methods of the staff. The doctors should be responsible and concerned with their
patients, first of all, they should inform the patients of the possible risks. In addition, it shows the
problem of ethic, on one hand, doctor's negligence, and on the other patient's demand for a safe and
efficient treatment.
To address these ethical issues effectively, it is crucial to prioritize education and training, implement
quality control principles, encourage open dialogue, and request explanations in case of errors. By
doing so, we can enhance the quality of surgical procedures in the cosmetic field and improve longterm health outcomes, reducing the risk of complications such as nerve damage. (Cleveland Clinic).
1.4. Blood Clots
Postoperative blood clot formation is one of the most grievous complications any patient, even a
cosmetic surgery patient, may face after any surgery. Such clots may lead to DVT and PE. DVT, medically
termed, is a deep clot in some vein- usually in the leg. Such a blood clot can dislodge, travel to the
lung, and produce a potentially lethal condition known as pulmonary embolism.
Common risk factors for developing blood clots include smoking, obesity, immobility, and other
medical conditions.
Ethical considerations are necessary in cases of blood clots, especially in cases where prevention or
management proves not to be effective. Health care providers and surgeons have a duty of care toward
their patients when it comes to taking the necessary steps to prevent and manage complications such
as blood clots.
To address these ethical concerns, it is required that there be education and training, the imposition
of quality assurances, open communication, and the responsibility of healthcare providers. Addressing
these considerations would help ensure that cosmetic surgery is always safe and effective-thus
reducing the chances of blood clots and other complications. (Mayo Clinic).
1.5. Scarring and Poor Wound Healing
Any surgical procedure, be it cosmetic surgery, is marked with the outcome of scarring. Though it may
seem unavoidable, proper care of the wound and surgical techniques can minimize this scarring effect
of any surgical procedure. The most devastating complications arising from poor wound healing are
possibly infection, dehiscence, and hypertrophic scars or keloids.
Because the negligence or lack of proper care leads to scarring or bad healing of wounds, an ethical
question arises. A duty of care applies to the surgeons and healthcare providers with regard to their
patients. Such surgeons and healthcare providers are to take appropriate measures that would help to
minimize scarring as well as allow the best possible healing of wounds.
Some of the key ethical concerns include informed consent, surgical technique, postoperative care,
and monitoring for complications. Mostly discomfort and pain will result from negligence or
inadequate care that leads to scarring or poor wound healing. There will also be complications that
will result in functional limits and financial handicap. There will also be loss of trust in the health
workers(Stanford Health Care).
1.6. Anaesthesia Complications
Anaesthesia is a major component of most interventions in cosmetic surgery. But anesthesia also
presents some risks and potential complications. The reaction to anesthesia can range from merely
side effects, but in some cases, these can be serious and life-threatening.
Preoperative assessment and monitoring during surgery are critical factors in avoiding or mitigating
complications involving respiratory problems, allergic reactions, malignant hyperthermia, anaphylaxis,
and respiratory depression. Tailoring plans of anesthesia delivery to individual patient needs is the role
of anaesthesiologists in securing their patient's safety.
Ethical issues arise whenever there is anesthesia complication as a result of negligence or poor care.
The duty of care of the surgeons and health care practitioners towards their clients comprises selection
of suitable anaesthesia, close monitoring of patients, and prompt attention to any form of
complications.
The main ethical considerations involved include consent, preoperative evaluation, monitoring during
surgery, and response to complications. When such complications occur and are directly due to
negligence or lack of proper care, the relevant health complications may become severe; financial
troubles may be encountered; even trust between the patient and healthcare provider may be lost.
Thus, the ethical concerns identified would require education and training for anesthesiologists, to be
accompanied by quality assurance measures and open communication, and with responsibility placed
with the health care providers, to critically address these considerations would ensure that cosmetic
surgery would then be done safely and effectively, risking anesthesia complications. (Verywell Health).
2. Regulations in Cosmetic Surgery
2.1. United States
Under this practice, cosmetic surgery in the United States does not have a uniform regulatory
framework that brings about standards and hence differs among states. That means fragmentation
can be brought about, and ultimately there will be poor care as well as unsafe services for patients.
Although the American Society of Plastic Surgeons (ASPS) does establish industry guidelines, an
absence of federal regulations leaves a lack in uniform supervision to monitor equivalent compliance.
There have been attempts to redress this flaw and establish a more integrated regulatory system that
safeguards patients and upholds acceptable practices in cosmetic surgery. (Plasticsurgery.org).
2.2. United Kingdom
Some of the main regulating organizations in the United Kingdom include the General Medical Council
and the British Association of Aesthetic Plastic Surgeons, among others. BAAPS is mainly concerned
with issues of informed consent, patient safety and ethical advertisement. The GMC requires that
surgeons must be properly trained and hence provide sound information on the risks and benefits of
a particular surgical procedure to the patient concerned.
BAAPS also encourages lifelong learning and bans misleading advertising that gives people a false
sense of hope for the future. With that said, enforcement is still a problem with the cosmetic
treatments with Botox or dermal fillers, mainly offered by those not qualified enough to administer
them, which in turn endangers the patients since it falls under less regulated treatments.
Recent reforms have included the Keogh Report and its reforms, such as the JCCP aiming to regulate
non-surgical treatments, whereas medical tourism continues to appear as an offshoot of travel where
cheaper operations are sought from clinics abroad. This then increases the dangers of coming
complications once the patient returns to the UK. Though regulations in the UK have been done right,
there are still loopholes in enforcement and oversight, and more must be done for the full protection
of patients. (NCBI).
2.3. Italy
Italy uses a more regulation and control approach where patients can be assured of safety in cosmetic
surgery. Italian law is substantially different from many states in that it focuses on the training and
accreditation surgeons must acquire before they are allowed to perform surgery and specifically
aesthetic or cosmetic procedures. Italian law creates two separate categories of surgery: aesthetic, or
cosmetic, and reconstructive or plastic. This further helps to maintain control over, in theory at least,
which practitioner is trained to do which procedure. It also requires practitioners to keep their skills
updated through ongoing education and skills enhancement in matters of safety procedures and
techniques. Italy's regulatory bodies also maintain such practices with an ethical approach, particularly
in honest advertising and patient counseling; hence, a person is fully aware of the risks and the
probable outcome of the surgery. The two countries confirm that improvements on safety standards
and ethics are upheld in cosmetic surgery to keep the industry expanding. (AME Groups).
Country
Most
Common
Procedures
Complication
Common
Rate (%)
Complications
Key Ethical
Concerns
Reference
United
States
Breast
Augmentation, 10-15%
Liposuction
United
Rhinoplasty,
Kingdom Liposuction
Italy
8-12%
Breast
Augmentation, 9-13%
Facelift
Infections,
scarring,
dissatisfaction
Informed
Sarwer et
consent,
al. (2007)
commercialization
Asymmetry,
infection,
hematomas
Patient
expectations,
overtreatment
ISAPS
(2020)
Nerve
damage, poor
scarring
Ethical marketing,
patient safety
Pittman
et al.
(2019)
3. Patient Satisfaction and Psychological Impact
3.1. Surgeon-Patient Relationship
Among those bonds, a surgeon-patient relationship can be told to decide the successfulness and
satisfaction of cosmetic surgery. Confidence and communicative skills are just the beginning of this
kind of bond, and a large deal of it is established even before the procedure itself. A good surgeonpatient relationship ensures that patients feel understood, informed, and supported throughout the
process.
It would also involve discussing over realistic expectations; that is, discussing the possible outcomes
of the surgery, the risk involved, and the steps required in postoperative care. Transparence regarding
the limitations and possibilities of the surgery might enable the patients to take informed decisions for
the surgery itself and prevent disappointment and regret. Not only does this transparency create trust,
but managing the expectations of the patients holds an important position in ensuring their long-term
satisfaction
with
the
outcome
(Plastic Surgery.org).
3.2. Psychosocial Benefits and Risks
Cosmetic surgery can provide substantive psychosocial benefits in most patients by enhancing selfesteem, body image, and quality of life. Where patients have been self-conscious about a certain
feature, surgery can offer an important relief into confidence and health social interactions lowering
their anxiety. This leaves many patients who go through surgery feeling much more at ease in their
own skins, sometimes affecting people's personal and professional lives favorably. This is most evident
when the goals are realistic in their expectations and truly know what surgery can and can't do for
them. Cosmetic surgery is a very profound experience when the goal matches the achievable results
of surgery - not only improving the look but also the mental and emotional well-being.
The psychosocial risks, however, should not be ignored. It may lead to unhappiness, frustration, and,
in some instances, remorse on the part of the patients when they are not given or cannot experience
the expected modification or significant improvement, especially if it is one that makes a difference
for life. These patients, who enter into surgery believing that their issues will be somehow more deeply
resolved, often go out with disappointment or worsening of a previous mental health disorder. For
this, to worsen the situation, patients with underlying psychological disorders like BDD are particularly
vulnerable to dissatisfaction and may continue in seeking further surgeries to seek unattainable
perfections. (Aesthetic Surgery Journal).
Findings
The findings of the systematic review reveal that complications in cosmetic surgery, such as
infections, scarring, nerve damage, and dissatisfaction, vary by procedure and are more common in
regions with less stringent medical regulations. Ethical concerns are prominent, especially regarding
inadequate informed consent, overtreatment driven by commercialization, and psychological
impacts on patients with unrealistic expectations. Medical tourism increases the risk of
complications due to lower regulatory standards and limited follow-up care. Globally, there are
significant differences in safety protocols and ethical practices, with stricter regions reporting better
patient outcomes and fewer complications
Conclusion
The systematic review highlights significant concerns regarding both the physical complications and
ethical issues associated with cosmetic surgery. While advancements in surgical techniques have
improved safety, complications such as infections, scarring, and dissatisfaction remain common,
particularly in regions with less stringent regulations. Ethical challenges, including inadequate
informed consent, overtreatment, and the psychological impacts of surgery, are exacerbated by
commercial pressures and medical tourism. To address these issues, stricter global regulatory
standards, enhanced patient education, and a greater focus on ethical practices are essential for
improving outcomes and ensuring patient safety in cosmetic surgery worldwide.
References
1. Cleveland Clinic. "Plastic and Reconstructive Surgery." Retrieved from Cleveland Clinic.
Multiple Authors
2. Mayo Clinic. "Cosmetic Surgery." Retrieved from Mayo Clinic.
Mayo Clinic's medical experts.
3. Healthline. "Most Common Plastic Surgery Complications." Retrieved from Healthline.
Medically Reviewed by Deborah Weatherspoon, Ph.D., MSN
4. WebMD. "What to Know About Plastic Surgery Risks." Retrieved from WebMD.
Medically Reviewed by Debra Jaliman, MD on May 12, 2023. Written by WebMD
Editorial Contributor
5. NCBI. "Advertising and Public Deception in Plastic Surgery." Retrieved from NCBI.
World J Plast Surg. 2016 Sep; 5(3): 207–212.
6. Journal of Ethics AMA. "Plastic Surgery's Contributions to Surgical Ethics." Retrieved from
Journal of Ethics AMA.
Chad M. Teven, MD and Scott B. Grant, MD, MBE
7. Harley Street MD. "Ethical Issues in Cosmetic Procedures." Retrieved from Harley Street MD.
Dr. Chia Tan
8. Public Ethics. "The Ethics of Cosmetic Surgery." Retrieved from Public Ethics.
Heather Widdows
9. Nuffield Bioethics. "Cosmetic Procedures Guide to the Report." Retrieved from Nuffield
Bioethics.
Published by Nuffield Council on Bioethics
10. Plasticsurgery.org. "Evidence-Based Clinical Practice Guidelines." Retrieved from
Plasticsurgery.org.
Connect, American Society of Plastic Surgeons
11. NCBI. "Cosmetic Surgery Regulatory Challenges." Retrieved from NCBI.
Danielle Griffiths, and Alex Mullock
12. AME Groups. "Regulatory Frameworks in Plastic and Cosmetic Surgery." Retrieved from AME
Groups.
Bryan Lim, Ishith Seth, Gianluca Marcaccini, Pietro Susini, Roberto Cuomo, Warren
M. Rozen
13. Aesthetic Surgery Journal. "Patient Satisfaction Following Cosmetic Surgery." Retrieved from
Aesthetic Surgery Journal.
David B. Sarwer, PhD, Lauren M. Gibbons, Leanne Magee, James L. Baker, MD, Laurie
A. Casas, MD, Paul M. Glat, MD, Alan H. Gold, MD, Mark L. Jewell, MD, Don LaRossa,
MD, Foad Nahai, MD, V. Leroy Young, MD
14. Healthline. "10 of the Most Common Plastic Surgery Complications." Retrieved from
Healthline.
Written By Teresa Bergen, Edited by Frank Crooks, Medically Reviewed By
Deborah Weatherspoon, Ph.D., MSN
15. Better Health Channel. "Cosmetic Surgery." Retrieved from Better Health Channel.
Victoria State Government
16. Stanford Health Care. "Complications Associated with Reconstructive Plastic Surgery."
Retrieved from Stanford Health Care.
Stanford Medicine
17. NCBI. "Complications in Cosmetic Surgery: A Time to Reflect." Retrieved from NCBI.
J Cutan Aesthet Surg. 2015 Oct-Dec
18. Public Ethics. "The Ethics of Cosmetic Surgery." Retrieved from Public Ethics.
Heather Widdows, May 23, 2022
19. NCBI. "Ethical Considerations in Plastic Surgery." Retrieved from NCBI.
J Cutan Aesthet Surg. 2010 Jan-Ap
20. Journal of Ethics AMA. "Ethical Considerations in Plastic and Reconstructive Surgery."
Retrieved from Journal of Ethics AMA.
AMA J Ethics. 2018;20
21. NCBI. "Plastic Surgery Complications: A Review for Emergency Clinicians." Retrieved from
NCBI.
West J Emerg Med. 2020 Nov
22. NCBI. "Complications of Cosmetic Surgery Abroad." Retrieved from NCBI.
J Cutan Aesthet Surg. 2015 Oct-Dec
23. NCBI. "Painful Complications After Cosmetic Surgery." Retrieved from NCBI.
World J Plast Surg. 2016 Sep; 5
24. Aesthetic Surgery Journal. "Patient Satisfaction and Psychosocial Status Following Cosmetic
Surgery." Retrieved from Aesthetic Surgery Journal.
David B. Sarwer, PhD, Lauren M. Gibbons, Leanne Magee, James L. Baker, MD, Laurie
A. Casas, MD, Paul M. Glat, MD, Alan H. Gold, MD, Mark L. Jewell, MD, Don LaRossa,
MD, Foad Nahai, MD, V. Leroy Young, MD
25. NCBI. "Ethical Issues in Considering Transsexual Surgeries as Aesthetic Plastic Surgery."
Retrieved from NCBI.
J Cutan Aesthet Surg. 2010 Jan-Apr; 3
26. NCBI. "Medical Ethics in Plastic Surgery: A Mini Review." Retrieved from NCBI.
World J Plast Surg. 2016 Sep; 5
27. NCBI. "Regulatory Frameworks in Plastic and Cosmetic Surgery." Retrieved from NCBI.
Health Care Anal. 2018; 26
28. AME Groups. "Global Regulations and Standards in Cosmetic Surgery." Retrieved from AME
Groups.
Lim B, Seth I, Marcaccini G, Susini P, Cuomo R, Rozen WM. Regulatory frameworks in
plastic and cosmetic surgery: a comparative scoping review across Australia, United
Kingdom, and Italy. Gland Surg 2024
29. NCBI. "Risks and Complications of Cosmetic Surgery." Retrieved from NCBI.
West J Emerg Med. 2020 Nov; 21
30. NCBI. "Patient Safety in Procedural Dermatology." Retrieved from NCBI.
J Cutan Aesthet Surg. 2015 Oct-Dec; 8
31. NCBI. "Patient Satisfaction in Cosmetic Surgery." Retrieved from NCBI.
Plast Reconstr Surg.
32. NCBI. "Psychosocial Issues in Cosmetic Surgery Patients." Retrieved from NCBI.
Plast Reconstr Surg.
33. Aesthetic Surgery Journal. "Predictors of Satisfaction in Cosmetic Surgery Patients." Retrieved
from Aesthetic Surgery Journal.
David B. Sarwer, PhD, Lauren M. Gibbons, Leanne Magee, James L. Baker, MD, Laurie
A. Casas, MD, Paul M. Glat, MD, Alan H. Gold, MD, Mark L. Jewell, MD, Don LaRossa,
MD, Foad Nahai, MD, V. Leroy Young, MD
34. NCBI. "Economic and Social Pressures in Cosmetic Surgery." Retrieved from NCBI.
World J Plast Surg. 2016 Sep; 5
35. NCBI. "Informed Consent in Cosmetic Surgery." Retrieved from NCBI.
J Cutan Aesthet Surg. 2010 Jan-Apr; 3
36. Public Ethics. "Advertising and Public Deception in Cosmetic Surgery." Retrieved from Public
Ethics.
Heather Widdows
37. NCBI. "Patient Autonomy vs. Non-Maleficence in Cosmetic Surgery." Retrieved from NCBI.
World J Plast Surg. 2016 Sep; 5
38. Journal of Ethics AMA. "Ethical Dilemmas in Plastic Surgery." Retrieved from Journal of Ethics
AMA.
Chad M. Teven, MD and Scott B. Grant, MD, MBE
39. Public Ethics. "Economic and Social Pressures Driving Cosmetic Surgery." Retrieved from
Public Ethics.
Heather Widdows, May 23, 2022
40. Nuffield Bioethics. "Addressing Vulnerability in Cosmetic Surgery Patients." Retrieved from
Nuffield Bioethics.
Published by Nuffield Council on Bioethics, 28 Bedford Square, London
41. AME Groups. "Ensuring Patient Safety in Cosmetic Surgery." Retrieved from AME Groups.
Bryan Lim, Ishith Seth, Gianluca Marcaccini, Pietro Susini, Roberto Cuomo, Warren M. Rozen
42. Plastic Surgery.org. "Building Trust in Surgeon-Patient Relationships." Retrieved from Plastic
Surgery.org.
Published by Wolters Kluwer.