Only MD, DNB Dermatology, MCh, DNB Plastic surgery should perform Aesthetic Surgeries including Hair Transplant: NMC

New Delhi: Ordering a crackdown on the mushrooming practice of unethical and illegal aesthetic surgeries including hair transplant, the National Medical Commission (NMC) has recently stated that only properly trained licensed registered medical practitioners (RMPs) i.e. practitioner of modern medicine are eligible for conducting such procedures.

Issuing guidelines, the Ethics and Medical Registration Board (EMRB) of NMC has recommended MCh/DNB Plastic surgery, MD/DNB Dermatology with adequate grooming in dermatological surgical procedures for conducting hair transplantation surgeries.

"It is also noted that the above-named specialties have Hair transplantation as a core topic in their curriculum," NMC explained in the guidelines.

Apart from this, the Apex medical body has also barred any untrained person from conducting such surgeries while noting that such procedures are not an "Emergency Surgery" and therefore, people cannot be allowed to conduct the surgeries under the pretext of "Exceptional Circumstances."

"It may be noted that watching in workshops or on YouTube, or any other similar platform, is not adequate training to start Aesthetic surgeries," clarified the Ethics Board of NMC.

In this regard, issuing a separate advisory, NMC has also informed the stakeholders about the possible harms of getting treatment from unqualified people.

Medical Dialogues had earlier reported that the Delhi High Court had taken note of the ongoing medical malpractice at the salons offering hair transplantation and aesthetic surgery procedures. Stressing upon the need of framing a national level protocol in this regard, the HC bench comprising of Justice Anoop Kumar Mendiratta had directed the Ministry of Health and Family Welfare, Government of India as well as Govt. of NCT of Delhi to ensure that such mushrooming Salons carrying hair transplantation procedures under unprofessional hands without requisite qualification and in absence of medical supervision, are checked.

Referring to the need for a protocol, the bench had back then noted the need for public awareness in this regard and the HC had also observed, "Also, the public at large needs to be made aware that such hair transplantation procedures/aesthetic surgeries can be fatal at the hands of unqualified professionals, which require strict medical supervision. In case any such medical protocols have not been established for guidance of medical practitioners, the same need to be framed at national level, in view of upcoming aesthetic surgeries and hair transplantation procedures," the court had further noted.

Referring to the hair transplantation surgeries, the HC bench had observed at that time that "Hair transplantation being an aesthetic surgery needs to be performed by qualified dermatologists or trained surgeons with informed consent of the patient."

Also Read: Mushrooming hair transplant centers: Court orders National Level Protocol for Doctors performing Hair Transplantation, Aesthetic Surgeries

Now the Ethics board of NMC has come up with a guideline for aesthetic surgeries and hair transplantation and has barred untrained professionals from conducting such procedures.

Hair Transplantation:

Referring to the hair transplantation surgery, NMC mentioned, "Any procedure involving a skin incision for the purpose of tissue removal from the scalp or body, or to prepare the scalp or body to receive tissue, (e.g., incising the FUE graft, excising the donor strip, creating recipient sites) by any means, including robotics, is a surgical procedure."

"Such procedures must be performed by a properly trained and licensed Registered Medical Practitioner (RMP) i.e practitioner of Modern Medicine. RMPs who perform hair restoration surgery must possess the education, training and current competency in the field of hair restoration surgery like adequate knowledge in hair physiology, pathogenesis of scarring and non-scarring alopecia, anatomy and physiology of scalp including scalp vasculature and nerve supply, adequate clinical skill to identify patients who are candidates for hair transplant surgery and contraindications for hair transplant including active scarring alopecia, adequate knowledge and clinical skill pertaining to the medical treatment of alopecia and pre and post-transplant medical care, acquired basic knowledge and skill base in surgeries pertaining to skin and its appendages, adequate training and knowledge pertaining to medical issues and possible adverse reactions that can arise during the hair transplant surgery including basic life support and resuscitation measures," NMC further noted in guidelines.

Mentioning its preference, NMC stated that "The hair transplant should preferably be undertaken only by those who have surgical grooming like formal surgical training such as MCh/DNB Plastic surgery, MD/DNB Dermatology with adequate grooming in dermatological surgical procedures."

The following aspects of hair restoration surgery should only be performed by a RMP:

• Preoperative diagnostic evaluation

• Surgery planning

• Surgery execution including: Donor hair harvesting, Hairline design, Recipient site creation and Management of other patient medical issues and possible adverse reactions

• Post-operative care

"It is unethical for a RMP to train an individual to perform/assist surgery who is not an accredited health professional licensed to do so," the guideline further specified.

Minimum requirements in a hospital/clinic performing hair transplant surgery:

The day care theatre should be equipped with facilities for monitoring and handling emergencies including stocking of emergency drugs, Boyles machine, intubation sets and ambu bag. A plan for handling emergencies should be in place and all nursing staff should be familiar with the emergency plan. It is ideal to have a standby anaesthetist.

Aesthetic Procedures:

As per the EMRB guideline, Aesthetic Procedures should be undertaken only by those RMPs who have adequate training to do these procedures as per their curriculum.

"So, curriculum of various specialties should be guiding principle for all RMP's while undertaking any procedure including aesthetics & Hair transplant procedures," it mentioned.

Aesthetic Procedures including Hair Transplant:

Pointing out that there might be complications due to the Aesthetic surgeries including hair transplant, the Ethics Board of NMC mentioned, "Aesthetic Procedures including Hair Transplant as with any other surgical procedure, may have complications and requires skills and training in appropriate patient selection, differential diagnoses and surgical techniques and appropriate post procedure care to optimize outcomes. It is suggested that anyone who wishes to perform these procedures should be adequately knowledgeable and trained and should ensure that they have adequate infrastructure and manpower to manage any issues that may arise due to procedure performed."

Further, the Apex medical body clarified that these procedures are not an Emergency Surgery and "hence there is no case for allowing any untrained person to do it under the pretext of "Exceptional Circumstances"."

In this regard, the guideline referred to Para 6 of the Judgment that mentions that "Hair transplantation being an aesthetic surgery needs to be performed by RMPs like qualified dermatologists or trained surgeons".

Advisory to stakeholders informing them about harms of getting treatment from unqualified people:

Prohibiting the untrained professionals from conducting these procedures, the NMC further specified certain guidelines as mentioned below:

(i)Patient should meet the doctor, who is going to perform hair transplant or aesthetic surgery and know his qualifications, experience.

(ii)Patient should be knowing about the place where such procedure is going to be performed, whether OT facilities with proper protocols etc. are there or not, with facilities and specialities to treat any postoperative complication.

(iii)Patient should be well informed about the procedure, all needed preoperative investigations, complications and requirement of procedure to be repeated etc.

(iv)Aesthetic Surgery including Hair transplant, as with any other surgical procedure, may sometimes have serious complications. Every RMP i.e practitioner of Modern Medicine should be aware of these complications and be trained with skills for their prevention and management as most of the complications are avoidable and can be minimized by proper surgical technique and wound care.

(v)Aesthetic Procedures including Hair Transplant require skills and training in appropriate patient selection, differential diagnoses and techniques and appropriate post procedure care to optimize outcomes and therefore, cannot be performed by anyone, anywhere. It is suggested that anyone who wishes to perform should be adequately knowledgeable and trained and should ensure that they have adequate infrastructure and manpower to manage such issues.

(vi)Aesthetic Procedures including Hair Transplant are not an Emergency Surgery and hence there is no case for allowing any untrained person to do it under the pretext of "Exceptional Circumstances".

"It may be noted that watching in workshops or on YouTube or similar platforms is not adequate training to start Aesthetic surgeries including hair transplant," the NMC guideline mentioned in this regard.

(vii)Assistants or technicians; should be from a medical background, such as nurses, OT technicians, pharmacists. However, they need to be provided structured, systematic and proper training in all aspects of aesthetic surgery, as well as the techniques for disinfection, sterilization, patient communication etc. Surgical assistants/technicians should perform their tasks only under the direct supervision of the treating physician.

(viii)Aesthetic Procedures including Hair Transplant should be performed only with an anaesthesia back up with the availability of all the requisite resuscitative equipment and drugs and with adequate preoperative clearances from the medical specialists and the anaesthetist.

"The RMP should have an anesthesia back up in the form of presence of the anesthetist in the operation room area with all the requisite resuscitative equipment and drugs in place," the guidelines mentioned.

"The RMP should ensure that the patient undergoing such a surgery should have adequate preoperative clearances from the medical specialists and the anesthetist," it added.

(ix)The center where Aesthetic Procedures including Hair Transplant are performed, should be registered as a Day Care Centre OR Hospital with the Local/ State Authorities and should have a well-equipped postoperative recovery room with facilities for monitoring of vitals including blood pressure, electrocardiogram, oxygen saturation etc.

(x)Also please note that Ghost Surgery (substitution of surgeons without the patient's knowledge and permission) would also constitute malpractice.

(xi)Further, unethical practices such as fee cutting and advertising with False/ exaggerated claims should not be indulged in.

(xii)Like any other surgical procedure, the record keeping for all aesthetic surgeries, including hair transplant is mandatory.

"Any violation of the above guidelines will be seen as a misconduct/offence as per existing law," the NMC advisory further read.

Manpower and Infrastructure required at place of such procedure:

Stressing upon the need for Manpower and Infrastructure at the place of Aesthetic surgeries including hair transplant, NMC Ethics Board has also laid down the rules in this regard.

Manpower:-

Apart from the surgeon performing hair transplantation and Aesthetic surgery, the centre should also have trained OT personnel like staff nurses, technicians, OT masters etc.

Infrastructure:-

1. It should be a hospital with facilities for treating indoor patients.

2. There should be properly set up operation theatre with all OT protocols being followed or implemented strictly like

a. Strict asepsis and fumigation protocols.

b. Proper biomedical waste management like separation, transfer/transport and disposal.

c. Proper sterilization of instruments, drapes etc.

3. Availability of anaesthetist as it is an Invasive OT procedure. Crash cart trolley should be available with all resuscitative facilities.

4. If it is a clinic doing day care surgeries only, then it should be well connected with any nearby hospital with proper ICU and critical care facilities, if needed in case of any emergency and with a display of 24 hrs emergency number for help.

5. Proper records of operated patients with pre and post operative photographs, records of any complication need to be maintained.

To view the official NMC guidelines click on the following link:-

https://medicaldialogues.in/pdf_upload/20220927051220-186422.pdf

To view the official NMC Advisory click on the following link:-

https://medicaldialogues.in/pdf_upload/20220927051354-186424.pdf