When Complications Happen: Why Even the Best Surgeons Can Face Risks—and Why Patients Must Look Beyond Registration
Surgery is often described as high-stakes, high-skill work, and for good reason. Even the most experienced, highly trained surgeons can encounter complications. That’s a reality that is uncomfortable but unavoidable. Every patient’s anatomy is unique. Healing varies. Some procedures are inherently complex. Even in the hands of a world-class surgeon, outcomes are not 100% predictable.
Yet, in today’s medical ecosystem, complications are too often misrepresented. Patients frustrated by outcomes may “doctor hop,” seeking someone else to blame. Worse, some colleagues use these moments to throw surgeons under the bus—sometimes subtly, sometimes overtly—claiming the complication is proof of incompetence. In the worst cases, surgeons are actively vilified because of professional registration technicalities rather than clinical skill.
This is particularly apparent in Australia, where highly trained surgeons like Dr. Darryl Hodgkinson who completed Plastic Surgery residency at the famed Mayo Clinic in the United States have been unfairly targeted by his Australian colleagues because they are not registered as plastic surgeons in the country, despite decades of international experience and clinical competence.
Appendix 15 - Letter from Dr Darryl Hodgkinson and attachments.pdf
Why Complications Happen—Even with the Best Surgeons
Surgery is not a machine; it is an interaction between a trained surgeon and a living, breathing, uniquely complex human body. Complications can occur due to:
(1) Case complexity – Patients who have undergone previous surgeries or have challenging anatomy due to threads/fillers and various energy devices present a “redo surgical terrain” that can increase the likelihood of complications.
(2)Healing variability – Age, nutrition (use of GLP injectables) or low calorie intake including low carb diets and Intermittent fasting (IF), smoking/vaping, chronic illnesses, and genetics all influence how the body recovers.
(3)Unexpected intraoperative events – Even the most meticulous planning cannot account for every variable.
Importantly, a complication does not automatically indicate medical negligence. Medical negligence occurs only when a surgeon’s care falls below the accepted standard of practice, as judged by peers in the field.
In contrast, many complications arise despite careful planning, skill, and adherence to professional standards. Mislabeling every complication as malpractice is misleading, harmful, and unfair to surgeons.
The celebrated neurosurgeon Henry Marsh and Surgeon General Atul Gawande emphasize that complications are an inevitable part of medical practice. What separates excellent surgeons from average ones is how they manage complications, communicate with patients, and learn from every outcome.
When Colleagues Exploit ComplicationsUnfortunately, some surgeons face more than just medical challenges—they face "professional politics". Complications can be weaponized by colleagues who have ulterior motives: turf wars, financial competition, or a desire to maintain control over a specialty.
Patients can be subtly brainwashed into believing they have been wronged if the operating surgeon is not formally registered as a specialist.
Take the case of Dr. Darryl Hodgkinson Despite being fully trained in the specialty of Plastic Surgery at the Mayo Clinic and internationally experienced, and highly competent, some colleagues encouraged patients to sue him simply because he was not registered as a plastic surgeon in Australia. The following sources provide insight into his professional challenges:
* Dr. Hodgkinson’s own letter and supporting documents
https://cosmeticmedicalpracticesubmission.info/appendices/Appendix%2015%20-%20%20Letter%20from%20Dr%20Darryl%20Hodgkinson%20and%20attachments.pdf
* [Sydney Morning Herald report on alleged cartel behavior among Australian surgeons]
https://www.smh.com.au/healthcare/australian-surgeons-accused-of-cartel-behaviour-to-control-fees-20160922-grm5rh.html)
The SMH article highlights systemic pressures where groups of surgeons allegedly attempted to control fees and restrict competition—a backdrop that makes it easier for colleagues to vilify competent surgeons who are “outsiders” to the system and are trained abroad or in another system.
Registration vs Competence: Why Titles Aren’t the Whole Story
Many patients assume registration as a plastic surgeon guarantees the best outcomes. While registration is legally significant, it does not necessarily indicate experience or skill in every cosmetic procedure. Conversely, many surgeons who are not registered as plastic surgeons in their country Australia for example - Dr Patrick Tansley (British trained plastic surgeon & former Hunterian professor) and Dr Darryl Hodgkinson (American trained plastic surgeon and founder of an International Cleft Mission Society - Operation Restore Hope) have extensive training, including accredited aesthetic surgery programs, and are perfectly capable of delivering excellent outcomes.
Dr Patrick Tansley FRCS Plast was denied entry to the Australian Specialist Register
[ACCSM Guidance on Qualifications and Competence in Cosmetic Surgery (PDF) emphasizes that specific training, experience, and professional development can matter more than formal registration especially in aesthetic plastic surgery.
https://www.accsm.org.au/download/?id=media&doc=189
[PMFA Newsdiscusses how registration and specialist status are distinct from actual procedural expertise.
IN RESPONSE TO: Plastic surgery and aesthetic medicine - specialties and specialists | The PMFA Journal
Liposuction | The PMFA Journal
https://www.thepmfajournal.com/features/post/plastic-surgery-and-aesthetic-medicine-specialties-and-specialists
Professor Dr Andrew Burd and Dr Lee Seng Khoo on Training and Competence
Dr. Andrew Burd and Dr. Lee Seng Khoo, in their PMFA journal articles, underscore a critical principle: competence in aesthetic surgery comes from specific, structured training, case experience, and continuous professional development—not solely from registration as a plastic surgeon. Key points from their paper include:
1. Procedure-specific training matters most – A surgeon may be registered in plastic surgery but have limited experience in a specific cosmetic procedure for example a complex procedure such as RibXcar https://nypost.com/2025/03/31/lifestyle/women-are-spending-20k-to-shrink-their-waists-in-viral-craze-experts-call-ribxcar/ or orthognathic two jaw surgery https://www.mahoganyoralsurgery.com/double-jaw-surgery/#:~:text=Double%20jaw%20surgery%2C%20also%20known%20as%20bimaxillary,bite%2C%20or%20crossbite%20*%20Obstructive%20sleep%20apnea.
Competence comes from dedicated practice in that procedure.
2. Mentorship and ongoing education are essential – Continual learning and peer-reviewed assessment improve outcomes and patient safety.
3. Outcome-based evaluation – Surgeons should be assessed by their results and complication management, not just by certificates or titles.
In short, PMFA guidance emphasizes that training, skill, and professionalism are far better predictors of safe outcomes than registration alone.
International Examples: Lessons for Patients
Joe Niamtu a friend and surgical mentor of mine faced disputes with the American Board of Plastic Surgery but went on to become a world-leading facelift surgeon.
Joe Niamtu on LoveThatFace https://www.lovethatface.com/2008/09/14/only-use-a-board-certified-plastic-surgeon/ discusses how patients should focus on surgeon experience, outcomes, and procedural expertise.
https://www.styleweekly.com/a-battle-between-competing-surgical-fields-spills-into-the-courts-and-patients-are-caught-in-the-middle/
Niamtu had to fight for his right to be allowed to perform Facial Plastic Surgery including facelifts and eyelid surgeries in a court battle way back in the 1980. He won and as they say the rest is "history"!
Patrick Tansley FRCS Plast, a British trained plastic surgeon, faced systemic barriers and was refused entry to the Plastic Surgery specialist register in Australia despite being highly qualified.
Banned surgeon considers legal action | The Advertiser
Cosmetic Surgery Regulation in Australia: Who Is to Be Protected—Surgeons or Patients? - Patrick Tansley, Daniel Fleming, Tim Brown, 2022
Mr Patrick Tansley Supreme Court Libel Action Melbourne -
In the United States, the Skim Milk article highlights conflicts between facial plastic surgeons and traditional plastic surgeons, demonstrating how professional politics can distort public perception.
Battle Over Beauty : In Changing Face of a Turf War, Cosmetic Surgeons Gain Ground - Los Angeles Times
The Georgia Society of Plastic Surgery published an article called “Things Are Never What They Seem, Skim Milk Masquerades as Cream.” This article called plastic surgeons “cream” and facial plastic surgeons and cosmetic surgeons “skim milk.” A lawsuit for slander and libel was filed by the Facial Academy and the Cosmetic Association. E. Gaylon McCullough, MD, past president of the American Academy of Cosmetic Surgery and secretary of the Facial Academy of Plastic Surgery, testified at the trial. The jury returned a guilty verdict against the plastic surgeons and awarded the largest judgment in history against medical organizations. The plastic surgeons were told to pay $1.5 million in punitive damages.
[Skim Milk article]
https://www.lovethatface.com/files/2013/04/Should-Cosmetic-Surgery-be-Limited-to-Certain-Specialties1.pdf
How Evil Narratives Can Mislead Patients
Unscrupulous colleagues can manipulate patient perception in subtle ways:
* Suggest that complications automatically indicate malpractice
* Emphasize registration over competence to cast doubt on the surgeon (cases of Darryl Hodgkinson & Dr Patrick Tansley)
* Encourage unnecessary litigation to protect personal or financial interests
Patients must recognize: that not every complication is negligence, and specialty registration status alone does not define competence. Hitler managed to convince many a folk by brainwashing in his Neo-Nazi heyday, and yet no one stopped to think for themselves.
Excerpt from Article "Don't make Your patient a Victim - When Doctors Criticize Other Doctors"
When Doctors Criticize Other Doctors
“Doctors will throw each other under the bus,” said Susan H. McDaniel, M.D., lead author of the study from the University of Rochester Medical Center. “I don’t think they even realize the extent to which they do that or how it can affect patients.”
Provider jousting comes in many forms. When one physician criticizes another, both may be at increased risk for litigation. When a patient hears criticism, they may feel the care they received was inappropriate. The words they hear may lead them to seek legal counsel regarding litigation. A glance away, a look of incredulity or an offhand comment may also be enough to trigger the feeling that care was inadequate even if it wasn't.
How Good Surgeons Handle Complications
The hallmark of excellence in surgery is how complications are handled:
Transparency – Discuss risks and realistic outcomes openly.
Reflection– Analyze what occurred and refine techniques.
Empathy – Treat patients with understanding & respect, not blame.
Henry Marsh’s philosophy reminds us: complications are inevitable, but they are opportunities for improvement, learning, and better patient care.
Even when every accepted precaution is taken, the human body can heal unpredictably, which is why surgery always includes careful follow-up and candid discussion of possible outcomes.
Only 2 types of doctors never have surgical complications: those who don’t operate and those who aren’t truthful.
When considering cosmetic or reconstructive surgery:
1. Research qualifications and training carefully – Look beyond titles.
2. Evaluate procedural experience – Ask how many of the specific procedure the surgeon has performed.
3. Ask about complication management – Good surgeons will discuss risks openly.
4. Be aware of professional politics – Recognize when criticism may reflect turf wars rather than incompetence. And a medical professional who speaks ill of another not only violates the Hippocratic Oath but such behavior reflects on their own unprofessionalism and personal integrity in the "noble profession".
Henry Kawamoto MD world renowned Plastic & Craniofacial Surgeon, stated in his lecture at the Kawamoto workshop in Egypt that he will never respect any colleague who speaks ill of another colleague & as he says as professionals and decent human beings - first deal with the problem, refrain from bad-mouthing any colleague & realize that we were not there during the procedure and hence not in a position to judge. If we do judge, be a professional and judge quietly, heal adequately and be a good doctor.
5. Consult multiple sources – Use PMFA, Australian College of Cosmetic Surgery, and reputable articles to verify information which is non-biased.
EPILOGUE
A scar may widen unexpectedly. Swelling may persist longer than anticipated. A wound may heal unevenly. A small area of tissue may not settle exactly as planned. Occasionally, revision surgery becomes necessary—not because the original operation was careless, but because biology does not always follow textbook expectations.
This is true across all fields of surgery, including plastic and aesthetic surgery. Even in internationally respected centres, surgeons with extensive experience and excellent outcomes still encounter complications. What matters most is not whether a complication ever occurs, but **how it is anticipated, explained, recognised early, and managed responsibly.**
For this reason, responsible surgeons discuss risks before surgery, not after problems appear. Every operation carries known possibilities such as bleeding, infection, asymmetry, delayed healing, scar variation, or the need for further refinement. These are not hidden possibilities; they are part of the reality of operating on living tissue.
Patients often ask whether perfect results can be guaranteed. The honest answer is no surgeon can ethically promise perfection. Surgery improves, reshapes, reconstructs, and refines—but it always takes place within the limits of human anatomy, tissue response, circulation, scarring tendency, and healing biology.
This does not reduce the importance of skill. On the contrary, training and judgment matter enormously. Surgical experience helps reduce avoidable risk, improve decision-making, and guide safe responses when healing does not proceed exactly as expected. But even the most experienced surgeon cannot fully control every biological variable after an operation is complete.
The true measure of surgical professionalism is therefore not the unrealistic absence of all complications, but careful patient selection, thoughtful planning, technical discipline, close follow-up, and honest communication throughout recovery.
REFERENCES
* [Sydney Morning Herald – Australian surgeons accused of cartel behavior]
https://www.smh.com.au/healthcare/australian-surgeons-accused-of-cartel-behaviour-to-control-fees-20160922-grm5rh.html
* [ACCSM PDF – Qualifications in Cosmetic Surgery]https://www.accsm.org.au/download/?id=media&doc=189
* [Skim Milk – Facial plastic surgeons vs plastic surgeons] https://www.lovethatface.com/files/2013/04/Should-Cosmetic-Surgery-be-Limited-to-Certain-Specialties1.pdf
* [PMFA News – Specialist registration vs competence] https://www.thepmfajournal.com/features/post/plastic-surgery-and-aesthetic-medicine-specialties-and-specialists
IN RESPONSE TO: Plastic surgery and aesthetic medicine - specialties and specialists | The PMFA Journal
* [Style Weekly – Surgical turf wars in court https://www.styleweekly.com/a-battle-between-competing-surgical-fields-spills-into-the-courts-and-patients-are-caught-in-the-middle/
* [LoveThatFace – Board certification vs experience] https://www.lovethatface.com/2008/09/14/only-use-a-board-certified-plastic-surgeon/
* [Joe Niamtu – world leader in facelift surgery]https://www.lovethatface.com/
* [Darryl Hodgkinson – Letter and attachments PDF
Appendix 15 - Letter from Dr Darryl Hodgkinson and attachments.pdf
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