1. Purpose of the Code
2. Competencies
3. Registration
3. Medical Indemnity Insurance
4. Advertising and Marketing
5. Patient Consultation and Assessment
6. Non-Medical Staff Working with/for the Member
7. Fees
8. “Cooling Off Period”
9. Consent
10. Documentation
11. Investigations
12. Members’ Responsibilities with Respect to Facilities in which they Work and Other Staff with whom they Work.
13. Safe Timing of Procedures
14. Post-Operative Follow-up
14.1. Arrangements for out of hours and emergency cover
14.2. Expectations of Member’s behaviour if a ‘complication’ or un-favourable result
15. Surgeons Who Travel Long Distance to provide Treatment
16. Audit and Quality Assurance
16.1. Risk Analysis
17. Members who have Relationships with Device Manufactures, Distributors or the Pharmaceutical Industry
18. Use of the ISAR Logo
19. Mandatory Notifications
20. Compliance
21. Complaints made to ISAR about Members
22. Conflicts of Interest 2


Membership of the International Society for Auricular Reconstruction comes with responsibilities, which are set out in this document.

The Code is an amalgamation of the draft CEN Standard in Aesthetic Surgery, the BAAPS Code of Ethics and by reference to International Best Practice for similar Associations.

All doctors must comply with their appropriate national or European Legislation, with codes of practice set out by their regulatory authority and they must also follow the guidelines of body which issued their surgical qualifications.

The Public rightly expect the highest standards from their medical advisors and from surgeons in particular.

All ISAR members must act in the best interest of their patents to protect their health and improve their quality of life.
The European Standard in Aesthetic Surgery has set out a minimum standard of practice and this document sets out to define what ISAR members must adhere to these are underpinned by;

Achieving and maintenance of technical excellence in the practice of surgery.
Ethical Practice
Probity in practice
Compassion and caring

These must underpin relations with patients, colleagues, staff and all others with whom the surgeon comes in professional contact and with institutions with whom they work.


a) The requirements for ISAR membership are set out in the Constitution of the Association.

b) ISAR members must strive for excellence and maintain their skills. For Surgeons, these must be regularly assessed and appraised. Information a doctor must provide for Annual Appraisal, leading to revalidation, includes reflection on CPD, adverse events, patient feedback and 360 assessment.

c) Members must not conduct themselves, or their practice, in a way that brings the Association, or the practice of ear reconstruction surgery in to disrepute.

d) Members must ONLY work with in their area of competence.


Members must be registered with the appropriate regulatory bodies in any country of practice, and these details must be displayed publically.


a) Members undertaking procedures must possess professional indemnity insurance that is appropriate and adequate for practice in the Country in which the procedure is to be undertaken. If the indemnity insurance is held outside the country of practice the Member must inform the patient of this and of any potential financial/ regulatory implications for the patient.

b) Members must comply with national legislation and regulatory authority regulations concerning medical Indemnity insurance.

c) The Member must not act outside his/her area of expertise and insurance cover unless in a ‘life saving’ situation.


a) Advertising and marketing in any form must be legal, decent, honest, truthful and socially responsible.

b) Members are individually responsible and accountable for their actions and words, as well as the use of their names by any individual or entity. Members shall be subject to disciplinary action for violation of any of the specific aspects reviewed herein. Members are responsible for any advertising/marketing by any third party with whom they work or are associated.

c) Any individual, group or business with whom a Member is associated must follow national advertising standards. Members may advertise through public communications media such as professional announcements, telephone and medical directories, computer bulletin boards, Internet web pages and broadcast and electronic media. The information shall be factual and verifiable, and should adhere to national advertising standards and where available to National Medical Association Guidelines for advertising and the Law of the Land on medical advertising.

d) In addition:

a. The use of pictures in any material, printed or electronic, should be used only if a reasonable range of anticipated outcomes are presented.
b. Advertising discounts, time limited offers, raffle, surgery as quiz prizes or rewards, offers to cover patients’ costs etc. are not allowed.
c. Any scientific claims must be supported by references.
e. Advertorial, web and blog transparency must be assured and readers must be made aware of the fact in the text.
f. Practitioner’s qualifications must not be misrepresented and only the Registered Speciality in which the Member is qualified shall be used. No terms must be used that give the impression of qualification in another specialty.
g. Members, or the institutions with whom they work or are associated, must not make payments, provide remuneration of any kind or discounts for making patient referrals. Patients must expect that any referral is made in their best medical interest with out any financial inducement.
h. Failure to comply may comprise unprofessional conduct by the Member and sanctions, including expulsion, may be applied.
i. Members shall be entirely honest about their level of training and experience. In particular they shall not make false claims about knowledge gained from visits to centre’s of excellence. Such visits must not be misrepresented as a ‘fellowships’ or period of ‘training’ unless the post was a paid, accredited training position with ‘hands on’ surgical experience over a continuous period of several month.

All promotional opportunities shall adhere to the same standards of legality, decency, honesty, truthfulness and social responsibility.

Marketing materials shall be drafted and designed to safeguard patients from unrealistic expectations as a result of any medical or surgical procedure;

If models are used to depict the results of any procedure or treatment, this shall be stated clearly in any advertisements in journals, newspapers, magazines or other media.

The information published shall not make unjustifiable claims or offer cures/guarantees; services shall not be advertised by visiting or telephoning prospective patients, either in person or through a deputy; advertisements shall not offer discounts linked to a deadline date for booking appointments for aesthetic medical procedure or other date-linked incentives; financial incentives (vouchers, discounts) are strongly prohibited.

Members shall not be a financial intermediary; Members must not offer procedures/treatments as prizes in sweepstakes (lottery), competitions or charity auctions.

Performing procedures or treatments in makeover shows, or “reality TV” opportunities are strongly discouraged, as they may promote unrealistic expectations of what a procedure can achieve, although educational documentaries may be acceptable.

Members must be aware that a significant number of Surgeons who have been involved in such programs have subsequently been sanctioned by the GMC.

Members must not compensate or give anything of value directly or indirectly to a representative of the press, radio, television or other communication medium in anticipation of or in return for recommending the services for professional publicity.

Advertorials must be clearly marked as such.

Members may pay the reasonable cost of marketing services, but shall approve all communications before release, and shall retain a copy or record for one year;
Other professional association logos must only be used truthfully and where specifically allowed by the organisation in question;

Members shall be honest about their own experience with any treatment and openly declare known audit figures of complications and their own complication rate;

Members must be honest about the science behind any procedure they offer and how its safety and efficacy has been evaluated;

Members shall refer to patients as “patients” and not “clients”;

Members must not make payments or give remuneration of any kind to referring professionals or agents including promotional websites for making patient referrals. Patients must expect that any referral is made in their best interest and does not involve any financial transaction. Any financial relationship between the referring party and/or the Member and/or the facility must be declared to the patient.

Members must not make unsubstantiated claims e.g. Being the ‘best’, offering the ‘best service’ or being a ‘leading surgeon’, etc

Members will be held personally responsible for any violation of the Code of Ethics incurred by public relations, advertising or similar firm which he or she retains, or any entity that advertises on the Member’s behalf.


a) Members must assume personal responsibility for the consent process of any treatment under their direction.

b) Members shall give impartial objective advice during the consultation.

c) The pre-treatment, face-to-face consultation must be with the Member and a discussion and confirmation of consent must also occur with any other individual who is to undertake any procedure on the Member’s behalf.

d) Patients must be given clear verbal and, (where applicable), written information, in language they can easily understand, about the procedure (including expected outcomes, post-operative course, complications and long term sequelae) well in advance of the procedure, taking into account the Cooling Off Period for the level of procedure under discussion.

e) Any other professional involved in the consultation process on behalf of the Member must declare their name, expertise, qualifications and explain their role (e.g. junior doctor in training, medical secretary or nurse) and this must be annotated. Such practitioners should not be used as a ‘shortcut’ in the pre-treatment process for the Member, who will remain responsible for carefully assessing the patient and undertaking the consent process.

f) At the end of the first consultation, the Member shall make certain that the patient has been made aware of the risks and benefits of the proposed procedure and the patient shall be given the opportunity to digest the information and reflect on discussions before deciding to proceed.

g) Members shall ensure that patients are made aware that further consultations are advisable and are encouraged.

h) Members shall not associate with establishments that demand deposits for surgical treatments at the time of first consultation..

i) Members must ensure that processes designed to reflect intended outcome (e.g. computer generated images) must be accompanied by a disclaimer explaining the result cannot be guaranteed.


a. Assessment of the patient’s general health and a relevant examination including ASA grade if appropriate.
b. Assessment of patient expectations
c. Analysis and discussion of possible treatment options for the specific aesthetic concerns.
d. Assessment of the patient’s psychological state and onward referral if appropriate.
e. Request relevant tests and investigations.
f. Communicate relevant findings to appropriate colleagues involved in the patient’s care, including the family practitioner.
g. If the patient declines permission to communicate with the family practitioner , the fact must be recorded in the clinical notes and the implications of the decision communicated to the patient verbally and in writing (e.g. The potential cost implications of developing a medical post operative complications such as a DVT)
h. A pre-operative assessment of fitness for anaesthesia MUST be made at least 2 days before general, regional, spinal or any anaesthesia involving sedation.
i. If the anaesthetist advises that the planned program is not safe, that advice is final.


a) Responsibility for the patient’s care rests with the Member at all times while the patient is under the care of others who work with the Member unless care is formally handed over to another doctor of consultant status.

b) Any assistant to the Member must be suitably qualified and indemnified.


a) Members must disclose in writing any financial conflict of interest to patients (e.g. ownership of the surgical facility, associations with implant manufacturers.

b) Fees shall be transparent and patients must receive a full written explanation of the costs of treatment well in advance of the proposed treatment (c.f. Cooling Off Period).

This explanation must include the long-term financial implications of any emergency care, complications and revisions must be made clear to the patient.

c) Advertising fee discounts, time limited offers, raffles, surgery as quiz prizes and paying all or part of patients’ expenses etc is not allowed.

d) Members, or the institutions with whom they work or are associated, must not make payments, provide remuneration of any kind or discounts for making patient referrals. Patients must expect that any referral is made in their best medical interest with out any financial inducement.

e) Patients must be informed of the terms and conditions of any payment made, particularly deposits and the cancellation policy. Any deposit requested must be a reasonable proportion (e.g. 10-15%) of the total treatment cost

f) Fees for services provided by associates or employees, including trainees, must be appropriate to the experience and qualifications of the individual providing the service. The individual providing the service must receive the fee, previously agreed in writing, for providing the service.

g) Claims made to insurers and other providers must be legal and appropriate to the service provided.


Consent is an ongoing process extending from the time of first contact until the day of the aesthetic procedure.

Members must also be aware that ‘on line or remote consultation’ is not appropriate except for the provision of generic information. No final diagnosis, treatment plan or prescription (for medical or surgical treatment) shall be given WITHOUT a face-to-face consultation and ‘hands on’ examination.

The Member must ensure that the patient clearly understands the planned procedure, the risks involved.

In the planned procedure and the post-operative recovery required before the ‘booking’ is confirmed or any money changes hands consent forms and clinical notes must be contemporaneous and legible.

No patient shall undergo a procedure without completion of the consent process.

9.1 The Consent Process
The process shall include a clear explanation by the Member, in plain language the patient can understand, of;

a) The limitations of the procedure and any alternative procedures that may be available, including those not offered by the Member, must be clearly explained to prospective patients before any money changes hands to ‘book’ the procedure.

b) A full explanation of complications, including those frequently occurring and those, which are rare but serious. Personal complication rates must be given but must not be used to entice patient to undertake a procedure. If published complication rates are quoted, patients must be made aware that these DO NOT relate to the Member’s practice. Patients must be made aware that specific complications can and do occur regardless of the average quoted for the member or in general.
NB Risks must be stated in easily understood numbers e.g.1 in 200 is more easily understood than 0.5 %.

c) The discussion must include an explanation of the Member’s expectations of outcome.

d) The post-operative/treatment course the patient would be expected to take must be explained to the member.

e) Written information must be given as additional material and shall not take the place of an informed discussion.

f) Members must keep a record of both the discussions and of the information given to the patient. Both the Member and patient must sign the consent form.

g) The patients must be made aware of the facilities available in the hospital/clinic to which they will be admitted (e.g. rooms, day case facilities, RMO, critical care facility).

h) Patients who show reluctance to proceed with surgery on the day must not be given reassurance and encouraged to proceed. Best practice is to cancel or postpone the procedure and restart the process. Such patients must be refunded in full if they decide against surgery minus any previously declared non-refundable deposit.

9.2 Consent for treatment of those under 18
a) Aesthetic procedures on patients under the age of 18 years should be exceptional and only undertaken after a full assessment of the risks and benefits, including the health and psychosocial consequences.

It is recommended that the patient include their parents or guardians in the consent process. Parents/guardians written consent is not legally required above the age of 16 but their verbal agreement is recommended but not essential if the patient refuses.


a) Members must ensure that their notes, in any format, must be legible and must include the patient identification details (at least patient’s full name, date of birth) and practitioner’s signature and name.
b) The manufacturer’s name, serial numbers, batch and lot numbers of any devices or healthcare products that are used on a patient (e.g. implants).
c) Digital records, where possible, shall include the practitioner’s signature.
d) Members must ensure that the storage, handling and access to patient notes and details comply with national data protection legislation.
e) Members must ensure that notes and photographs shall be available to the patient at their request, they should be available within a reasonable time, and any charge made for copying notes should be appropriate and reasonable.
f) Levels of consent for photography must be explained to patients and the level given clearly recorded.
g) It is recommended that photographs, relevant to the treatment planned, should be taken for all patients undergoing ear reconstruction procedures. Photographs should be standardized where possible. Use of patient’s pictures is strictly limited to the use authorized, and signed for, by the patient in the consent form.
h) Patient photographs in any format shall be stored according to data protection legislation.
i) Members must ensure that patient confidentiality is respected at all times and that notes are only be released to third parties, which are not involved in the patient’s clinical care, with the patient’s signed consent.


a) Preoperative tests and investigations should be performed where appropriate. The practitioner should inform the patient of the financial implications.

b) Patients should be aware of the need for histological examination of any tissue specimens and the costs involved.


a) It is the Member’s responsibility to ensure that the facility in which they work has a current CQC registration where appropriate and that all the equipment that they will use or need to treat the patient is present and correct.

b) It is the Member’s responsibility to ensure that the staff of any facility, with whom they work, are appropriately qualified.

c) Members must comply with any appropriate National Legislation when working in any facility.

d) Patient safety is paramount in any care delivered by a member.

e) Members are now required by national legislation to ‘whistle blow’ if they feel facilities or staff are unsafe or not fit for purpose.


a) Members must inform patients if the timing of their procedure could introduce additional risks/complications (e.g. abdominoplasty at the time of caesarean sections).

b) Members shall inform patients of additional risks associated with a procedure can be reduced if the patient modifies their behaviour e.g. stopping smoking, weight loss, etc. When necessary, the member should decline to operate unless the behaviour in question is modified.

c) Members must inform patients if stopping of medication would reduce the risk of a procedure (e.g. aspirin or anticoagulants). Stopping prescribed medications must only be done with the GP’s or the Specialist’s agreement.

d) Members must inform patients that undergoing multiple procedures during one operation introduce a greater risk of complications.


a) Members must ensure that all patients shall receive a discharge summary on leaving the hospital/facility after a surgical procedure.

b) The summary should include information about the aesthetic medical procedure performed, post-operative medication prescribed, contact details in the case of an emergency and details of the first follow up appointment. Patient should be given any implant card/s for any device used.

c) Members have continuing responsibility for the care of their patients throughout the recovery period and must ensure that their patients have access to help at all time either from the Member or from another doctor who has been formally handed care of the patient. NB This does NOT include the RMO of the facility. Patients also have the obligation to attend their follow-up appointments. And to follow defined post-operative instructions.

14.1 Arrangements for out of hours and emergency cover
a) Members must provide patients with contact details in the case of emergency.
b) The Member would normally be expected to provide ‘out of hours’ care unless other arrangements have been made via a formal hand over, which has been explained to the patient.
c) If a Member is not available they must provide patients with appropriate alternative cover, of a similar level of professional expertise. A formal handover of patient care is expected when the Member goes on holiday or is more than 1hrs travel time away in the 24hours after a procedure has been undertaken It is not acceptable for a Member to hand over care to a third party because the Member does not live within reasonable proximity of the where the procedure was performed.
d) Members must ensure that the facility within which they perform surgery has appropriate service level agreements in place with critical care facilities if these are not available in the facility itself.
d) Members must ensure that there is appropriate anaesthetic cover in the case of emergencies.

14.2 Expectations of Member’s behaviour if a ‘complication’ or un-favourable result occurs
a) If a complication occurs or an outcome is less favourable than expected, Members must provide the patients with an open and honest explanation of what has happened. There must be no cover up of a medical error.

b) Members must ensure that the patient receives appropriate further treatment and a second opinion should be requested as necessary or if asked for by the patient.

c) When revision surgery is required, Members must take into account the out of pocket expenses incurred by the patient when calculating the fee for the revision.

d) If a Member treats the complication of another surgeon they must be mindful of any comments they make about the previous surgeon’s care.


Surgeons travelling long distances to provide surgical procedures must be aware of the implications for ongoing postoperative care and the medico legal implications for cover needed when they return to their normal place of work, residence or take annual leave:

a) Our members are advised to operate only within the proximity of their official residence where they can provide continued postoperative care.
b) A number of medico legal cases have previously highlighted the responsibility that the travelling surgeon has within the UK to attend to a patient when the surgeon has travelled away from their place of residence. Lack of appropriate post operative care when the surgeon has been travelling to perform surgery has previously lead to individuals being removed from the medical register and was also highlighted in the 14 year review of medico legal cases by the MDU published in the Journal of Clinical Risk (2009; 15: 241-243)
c) Members must inform patients in writing if they are ‘travelling a long distance’ to provide treatment.
d) If a member travels away from his or her place of residence to treat patients and there is a complication after surgery they have the responsibility to travel to the patient rather than the reverse. This has been the finding of several previous medico legal cases and is now accepted as the legal precedent.
e) The member must inform the patient of the importance of follow up after surgery.
f) Patients must be informed in writing of what they can expect to happen should problems arise.
g) Documentation must be made of discussions explaining the difficulties of dealing with complications or dissatisfaction when the surgeon has to travel to perform surgery. This information should form part of the consent process.
h) When a travelling member, whose practice is based away from home, goes on annual leave the consultant surgeon covering the practice needs also to be prepared to travel to the multiple sites that the travelling surgeon attended and must be aware of this.
i) Patients need to be aware in writing what the cross cover arrangements are for any period of annual leave so the place of attendance in an emergency is clear.
j) Members, must not recommend Insurance schemes that imply the responsibility for looking after complications can devolve to a third party. Such policies can also be viewed as an inducement, by making a potentially dangerous process appear slightly more attractive but no less dangerous.
k) Where patients travel to a named member surgeon, the member has a responsibility to inform the patient of the risks of travelling a long distance to see and be treated by them especially when the patient is travelling their own country, follow up under this circumstance is different to the travelling surgeon as the patient has a responsibility to travel to the surgeon having made the decision to seek their treatment initially.
l) Members must inform patients travelling long distances for treatment of their professional indemnity arrangements and of those of any Clinic/Facility they may use.
g) Members must not offer medical services in any country unless they are fully approved and registered to do so by the national regulatory authority of that country. Members should note that in many countries the process of medical consultation constitutes medical practice and that this requires appropriate registration with the national regulatory authority of that country.


These aspects of care are the cornerstones of good medical practice and Members must adhere to them.
The Audit/Quality Assurance and improvement information required for revalidation shall consist of 6 pieces of evidence:
1. Continuing professional development
2. Quality improvement activity
3. Significant events
4. Feedback from colleagues
5. Feedback from patients
6. Review of complaints and compliments

16.1 Risk Analysis
A Member shall not undertake any procedure requested by a patient where the Member believes there is an unacceptable risk to the patient.
Members must report adverse events, which involve a medical device, drug or other medical product, to the relevant authorities as per institutional and/or National guidelines.
Route Cause analysis shall be used in the assessment of complications and emergencies.

NB General guidance for risk analysis is provided in ISO 31000, including
Principles: Risk management creates and protects value, is an integral part of all organizational processes, is part of decision making, explicitly addresses uncertainty, is systematic, structured and timely, is based on the best available information, is tailored, takes human and cultural factors into account, is transparent and inclusive, is dynamic, iterative and responsive to change and facilitates continual improvement of the organization. Framework based on a Plan-Do-Check-Act process.


a) Members must comply with national legislation in this matter.
b) Members must not receive any remuneration or payment in kind, goods or services based on the understanding that the Member will use a device, implant or drug.
c) Members must not enter into any financial arrangement that could be seen to influence decisions made in the care of their patients. Any arrangement must withstand legal, public, professional and media scrutiny.
d) Conflicts of interest must be declared in writing to patients and to the Association, which will keep a Register of Conflicts of interests. Potential conflicts of interest include amongst others;

a. Directorships of companies in the healthcare industry.
b. Membership of other Professional Associations, including holding Offices in other Associations.
c. Grants from Industry, outside an approved clinical trial,
d. Sponsorship for attending Scientific Meetings.
e. If a member invents or helps develop a product (device, technique or drug) that must be declared to patients on whom it may be used outside of any approved clinical trial.


a) The Association does not endorse any company, medical product, medical device or group of surgeons.
b) Membership of the Association is on an individual basis and is not open to companies, group of surgeons and hospitals/clinics.
c) Members must not use the name or logo of the Association in any way that might bring the Association into disrepute.
d) Members must not make the suggestion or imply they are speaking for or on behalf of the Association unless asked to do so by the President of the Association or ISAR Media Officer.
e) Use of the Association logo by Members is restricted to use on personal websites and stationary to show personal affiliation and on promotional material associated with courses or meeting that are endorsed by ISAR. It must not be used in any way to imply that the Association endorses any company or group of surgeons or that all members of a company/group are Members of ISAR.
f) The ISAR logo must not be used in any advertising materials except promotional material for courses or symposia endorsed by ISAR with the explicit permission of the ISAR president or secretary general.


Members must notify the Association of any retirement from practice for any reason and of any
Regulatory authority , criminal or civil ruling made against them that would prevent them practicing as a surgeon or doctor, within 5 working days.


a) On being elected to Membership, new Members will be required to sign an acknowledgement that they have received the Code of Conduct, read it and agree to be bound by the Code.
b) Amendments to the Code must be discussed and agreed at Council by simple majority and put to the next AGM for approval.
c) Amendments to the Code will require a simple majority at the AGM to be adopted.
d) The President, the President Elect and the Immediate Past President can take action under the Code under exceptional circumstances if the event is not covered by existing clause but their action will need to be ratified subsequently by Council.
g) Any new version of the Code will supersede all previous versions.
h) Each Member of the Association must sign an acknowledgement that they have received, read and agree to abide by the new Code.
i) Failure to accept and abide by the Code will nullify membership.


a) The member must inform, in writing, all patients of their complaints procedure.
b) The President or a member of Council nominated by the President will respond to any signed complaint received in writing about a Member.
c) The member will be informed of the complaint within 14 working days by email and/or post.
d) The complaint will be referred to the Present, Past and Incoming Presidents for investigation (a.k.a. The Ethics Committee).
e) Action taken by the Association will depend on the outcome of the investigation. Any action deemed to be criminal, against regulatory authority guidelines, Legislation or deemed to bring the Association into disrepute may result in instant expulsion. Otherwise, any sanction will be discussed at Council and their decision will be final. Outside agencies may be informed of the nature of the complaint depending on it’s nature.
f) Upheld complaints will remain on a Member’s file for 5 years and they will be taken into account if subsequent complaints are received on different matters.
g) Actions following investigation of a complaint may be;

a. Dismissal of the complaint
b. Recommendation that the Member undergo counseling or other course of action.
c. The Member must sign a statutory declaration that they will abide by the Code in future.
d. Imposition of conditions on the Member’s Membership
e. Suspension of Membership (N.B. Two suspensions will normally result in expulsion)
f. Expulsion from Membership.


All Members are required to register any possible Conflicts of Interest with the Secretariat. An annual reminder will be sent to members but it is the Member’s responsibility to inform ISAR of any change in their Conflicts of Interest in year.
Examples of possible Conflicts are;
a) Membership and Office Holders of other Surgical Societies.
b) Directorships of companies working in the medical sector (‘providers’ of health care including insurance
and financial products/drug companies/surgical device, instrument or implant manufacturers.
c) Being in receipt of payments of any sort from any source, except for those received as part of an ethically approved trial’, e.g. honoraria, research grants, bursaries, ‘goods in kind’, including travel costs.