Cenk Demirdöver, Mark Henley, Dirk J Schaefer, Nora Nugent, Jan A Plock, Adam J Reid, Riccardo Giunta, Radu Olariu, Adrien Daigeler, Nuno Fradinho, Cristian Radu Jecan, Ilkka Kaartinen, Reuf Karabeg, Dolores Wolfram, Jacques Saboye, Cesare Tiengo, Rado Zic
European plastic surgeons describe a fragmented landscape in which a regulated core coexists with an unregulated commercial periphery. ESPRAS proposes a four-pillar framework-public surgeon registries, facility and facilitator accreditation, mandatory complication insurance, and harmonised European patient- and surgeon-facing guidelines-as the basis of a coordinated European response.
BACKGROUND: Demand for aesthetic surgery has risen rapidly, and the parallel growth in cross-border medical travel is increasingly burdening European health systems with imported complications. The perspective of board-certified plastic surgeons themselves-as both providers of cross-border care and managers of its complications-has not been systematically captured at a European level.
METHODS: An anonymous online questionnaire (43 items across three thematic sections) was distributed by the European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) to its member national societies between December 2025 and February 2026. The instrument addressed (A) the practice of surgeons treating international patients, (B) the management of complications from procedures performed abroad, and (C) safeguards and policy reform. Quantitative data were summarised descriptively; free-text responses were analysed thematically.
RESULTS: Two hundred and fifty board-certified plastic surgeons from 36 countries responded; 230/250 (92.0%) held national or international board certification. The most common procedures performed for international patients were breast augmentation (n=86), breast reduction/mastopexy (n=82), and abdominoplasty (n=80). Eighty-nine per cent of respondents had managed complications of procedures performed abroad in the preceding five years; abdominoplasty (n=144), breast augmentation (n=106), and liposuction (n=76) predominated, with wound dehiscence/necrosis (n=156) and infection (n=131) the most frequent patterns. Cost was the most often cited primary motivation for patients (49.8%); 79.2% of respondents identified board certification as the single most important verification criterion, and 77.2% identified profit prioritisation over patient safety as the principal facilitator-related risk. Mandatory international qualification standards (35.6%) and stricter facilitator regulation (23.6%) were the most frequently endorsed policy priorities.
CONCLUSIONS: European plastic surgeons describe a fragmented landscape in which a regulated core coexists with an unregulated commercial periphery. ESPRAS proposes a four-pillar framework-public surgeon registries, facility and facilitator accreditation, mandatory complication insurance, and harmonised European patient- and surgeon-facing guidelines-as the basis of a coordinated European response.