Introduction

In recent years, the demand for aesthetic procedures, both surgical and non-surgical, has spiked. According to the International Survey of the International Society of Aesthetic Plastic Surgeons (ISAPS) in 2022, an increase of 139.9% for all aesthetic procedures were reported when compared to the year 2010. Some countries were the main drivers of this trend and contributed to a larger extent than others: Central European countries such as Germany, noted a substantial increase of 190.5% in aesthetic procedures for the same observational period [1, 2]. This increase is also reflected in the number of German plastic surgeons obtaining board certification which more than doubled with 119% between 2010 and 2022 (from 747 to 1,638), while the total number of licensed German physicians (independent of their medical specialty) rose only by 26% (from 333,599 to 421,303) [3, 4]. These numbers undoubtedly highlight a growing public interest, demand and offer in plastic surgery, thereby reflecting the field's dynamic nature driven by evolving trends.

Plastic surgeons are confronted with the challenge to continually adapt and offer innovative treatments employing latest techniques and technologies to address the ever-changing beauty ideals of their patients. However, it is important to recognize that the wide field of plastic surgery encompasses more than just aesthetic surgery as this surgical specialty is often conceptualized as resting on four pillars: reconstructive surgery, hand surgery, burn surgery and aesthetic surgery. Still, the wide spectrum of plastic surgery and the roles it can play in medical care are often not being recognized in the public perception [5, 6]. This specialty’s broad scope effectively showcases the necessity for high degrees of specialization for optimal patient care in complex cases. Such specialization is typically found in large clinical centers and hospitals. Paradoxically, these institutions often do not adequately offer or integrate aesthetic surgery into their curriculum for plastic surgery residents [7,8,9,10]. To ensure universal access to specialized plastic surgery care, a tightly woven national network of plastic surgery practices – besides highly specialized clinical centers—is required. Yet, the extent to which this network consisting of plastic surgery practices can offer the full spectrum of this specialty with its four main pillars remains elusive.

Herein, we aim to provide an overview of the current trends and procedures offered in plastic surgery practices in Germany, Austria, and Switzerland, often referred to as D-A-CH countries. Our analysis will focus on both surgical and non-surgical procedures offered on the websites of plastic surgery practices, thereby aiming to unveal regional differences and potential healthcare gaps in plastic surgery care. Ultimately, this analysis aims to describe the “status quo” of plastic surgery care in the practice setting. The data presented in this study can serve as a foundation to outline potential future trends in this constantly evolving medical specialty.

Material and methods

Study setup

In this cross-sectional, multinational, website-based study, the information provided on the websites of n = 511 plastic surgery practices in Germany, Austria and Switzerland were analyzed. The websites of the plastic surgery practices were selected using the member search function of the German Association of Plastic, Reconstructive and Aesthetic Surgery (“Deutsche Gesellschaft für Plastische, Rekonstruktive und Ästhetische Chirurgie”; https://www.dgpraec.de/patienten/arztsuche/), the Austrian Association of Plastic, Reconstructive and Aesthetic Surgery (“Österreichische Gesellschaft für Plastische, Rekonstruktive und Ästhetische Chirurgie”; https://www.plastischechirurgie.org/arztsuche/) and the Swiss Association of Plastic, Reconstructive and Aesthetic Surgery (“Schweizerische Gesellschaft für Plastische, Rekonstruktive und Ästhetische Chirurgie”; https://plasticsurgery.ch/de/patientinnen-und-patienten/liste-der-plastischen-chirurgen). All non-retired plastic surgeons listed in the above-mentioned member registries were included in our analysis if they were working in a practice setting at the time of the data collection (November 2023 to January 2024). If multiple plastic surgeons shared the same practice, the respective practice was included only once in our analysis. All practices included in our analysis were owned by board-certified plastic surgeons. In most cases, the respective practice website was linked in the member details of the respective association’s member search function. If a website was not linked in the member details, this was either due to a) the plastic surgeon working in a non-private-practice setting (e.g., hospital) or b) the plastic surgeon not having provided their website address when signing up as a member in the respective association. In case of the latter, one author (K.S.) performed a Google search employing the name of the plastic surgeon to check if a practice and a corresponding website exists. If no website could be found after a meticulous search, it was assumed that the plastic surgeon did not work in a private practice. (Fig. 1).

Fig. 1
figure 1

Flowchart summarizing the selection process of plastic surgery websites included in our study

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The reason for the selection of these specific countries is the same language and cultural background (i.e., German as the official main language) and similar qualification requirements for board-certification in plastic surgery (i.e., six years of residency with a comparable curriculum). One investigator (K.S.) analyzed all websites to ensure consistency.

Ethics approval was not required due to the study’s nature which relies on the analysis of openly accessible data listed on the websites of the included plastic surgery practices. All data is published in an anonymized fashion, without reporting any identifying information on neither individual plastic surgeons nor their practices.

Analyzed parameters

The following general information about each practice was collected: name, website address, country, federal state, gender of owner, habilitation (i.e., (associate) professor), years since board certification, years since practice opening, and number of board-certified plastic surgeons in practice.

The procedures offered by the practice – as outlined on their website – were analyzed for the following domains:

  1. i)

    Reconstructive Surgery: a) Reconstruction after skin cancer, b) Craniofacial surgery for congenital anomalies, c) Reconstruction after infections, d) Tissue reconstruction after radiotherapy, e) Post-bariatric surgery after massive weight loss, f) Lymphedema surgery, g) Extremity reconstruction

  2. ii)

    Burn Surgery: a) Burn scar treatment/Skin transplantation

  3. iii)

    Aesthetic Surgery

    1. a.

      Head and Neck: a) Facelift, b) Necklift, c) Blepharoplasty, d) Rhinoplasty, e) Otoplasty, f) Forehead/Brow lift, g) Implant-based augmentations (e.g., chin, cheeks), h) Hair transplantation, i) Lip corrections (e.g., Bullhorn lift)

    2. b.

      Breast: a) Breast augmentation, b) Breast reduction, c) Breast lift, d) Gynecomastia surgery, e) Nipple correction, f) Breast implant removal, g) Breast reconstruction

    3. c.

      Body: a) Liposuction, b) Abdominoplasty, c) Brachioplasty, d) Flank Lift, e) Thigh Lift, f) Brazilian Butt Lift, g) Sweat gland suction, h) Buttock lift, i) Buttock augmentation, j) Mommy makeover

    4. d.

      Intimate region: a) Labiaplasty, b) Vaginoplasty, c) Phalloplasty, d) Gender-affirming surgeries, e) Penile enlargement

  4. iv)

    Non-surgical aesthetic procedures: a) Soft tissue filler injections, b) Neuromodulator injections, c) Hair removal (e.g., lasers), d) Laser-based skin treatments, e) Tattoo removal, f) Chemical peelings, g) Microdermabrasion, h) Radiofrequency-based skin tightening, i) PRP treatment, j) Cryolipolysis, k) Thread lifting, l) Mesotherapy, m) Microneedling, n) Ultrasound-based skin tightening

  5. v)

    Hand surgery: a) Trigger finger release, b) Osteosynthesis after fractures, c) Carpal tunnel syndrome, d) Nerve compression syndromes, e) Dupuytren’s contracture, f) Treatment of Osteoarthritis, g) Nerve injuries, h) Tendon injuries, i) Hand rejuvenation

Statistical analysis

Depending on the data structure, Pearson’s chi-square test (nominal variables) or Analysis of Variance (ANOVA) (continuous variables) was used. Unless indicated differently, all values are given as mean values (SD). All calculations were performed using SPSS Statistics 27 (IBM, Armonk, NY, USA), with statistical significance defined at a probability level of ≤ 0.05 to guide conclusions.

Results

General information

This study analyzed a total of n = 511 plastic surgery practice websites, including 314 in Germany, 113 in Austria, and 84 in Switzerland. Demographic analyses revealed that 22.5% (115) of practices were female-owned, 73.8% (377) were male-owned, and 2.7% (14) were co-owned by male and female plastic surgeons. A total of 12.3% (63) of plastic surgeons achieved a higher academic degree termed habilitation (equivalent to (associate-) professor status in other countries). Practices employed an average of 1.66 (1.2) specialists [range: 1—8]. The average time since board certification was 19.6 (7.6) years [range: 0—40], and practices had been operating for an average of 13.5 (7.5) years [range: 0—36]. The study found an average of 19.2 (7.0) [range: 0 – 49] different procedures – according to the procedures defined in our study’s methodology—offered per practice. Detailed data stratified for each country is summarized in Table 1.

Table 1 Details of the plastic surgery practices investigated in this study, stratified by country. Statistically significant differences are indicated in bold
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Procedures

Across the three investigated countries, the most frequently offered domain was Aesthetic surgery with 98.8% (506 out of 511), followed by Hand surgery at 29.7% (152 out of 511), Reconstructive surgery at 27.8% (142 out of 511) and Burn surgery at 5.7% (29 out of 511). (Fig. 2).

Fig. 2
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Illustration showing the distribution of procedures offered on the websites of the plastic surgery practices included in this study, when categorized into the four pillars of plastic surgery: aesthetic, reconstructive, hand surgery, and burn surgery

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Within the Aesthetic surgery domain, significant country-specific trends were observed when stratifying for body regions: Whereas procedures for the intimate regions were most commonly listed on German plastic surgery websites (51.9% (163) and p = 0.007), procedures for head and neck (100.0% (84) and p = 0.041), breast (100.0% (84) and p = 0.003), and body (100.0% (84) and p = 0.010) were most commonly listed on Swiss plastic surgery websites. (Figs. 3, 4, 5 and 6).

Fig. 3
figure 3

Bar graphs showing the percentage of various aesthetic surgical procedures in the head and neck region offered on the websites of the plastic surgery practices included in this study

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Fig. 4
figure 4

Bar graphs showing the percentage of various aesthetic surgical procedures of the breast offered on the websites of the plastic surgery practices included in this study

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Fig. 5
figure 5

Bar graphs showing the percentage of various aesthetic surgical procedures of the body offered on the websites of the plastic surgery practices included in this study

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Fig. 6
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Bar graphs showing the percentage of various aesthetic surgical procedures of the intimate region offered on the websites of the plastic surgery practices included in this study

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A statistically significant difference was noted in Reconstructive and Hand surgery listings, with Austrian practices listing these procedures more frequently on their websites compared to their German and Swiss counterparts: Reconstructive surgery (A vs. D vs. CH): 38.9% (44) vs. 24.8% (78) vs. 23.8% (20); and Hand surgery: 43.4% (49) vs. 30.6% (96) vs. 8.3% (7), with p = 0.011 and p < 0.001 respectively. (Figs. 7 and 8).

Fig. 7
figure 7

Bar graphs showing the percentage of various reconstructive surgical procedures offered on the websites of the plastic surgery practices included in this study. Burn surgery was included in this data presentation

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Fig. 8
figure 8

Bar graphs showing the percentage of various hand surgical procedures offered on the websites of the plastic surgery practices included in this study

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Non-surgical aesthetic procedures were listed on 87.9% (450) of all practices’ websites, with Swiss practices’ websites having them listed most often with 97.6% (82) and p = 0.001. Detailed data on specific procedures for each domain stratified by country is summarized in Table 2. (Fig. 9).

Table 2 Details of the procedures offered on the websites of the plastic surgery practices investigated in this study, stratified by country. Statistically significant differences (p ≤ 0.05) are indicated in bold
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Fig. 9
figure 9

Bar graphs showing the percentage of various non-surgical aesthetic procedures offered on the websites of the plastic surgery practices included in this study

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Discussion

Our study aimed to investigate the landscape and focus of procedures offered in plastic surgery practices in Germany, Austria, and Switzerland, by using openly accessible data sampled from their websites. The results collected were compared across countries and referenced against the four major pillars of plastic surgery: aesthetic surgery, reconstructive surgery, hand surgery, and burn surgery. The metaphorical structure of plastic surgery resting on four main pillars, appears at risk of collapse in actual practice settings. In this setting, plastic surgery often leans heavily on just one pillar: aesthetic surgery, with a fractional reliance on reconstructive and hand surgery, and an almost negligible reliance on burn surgery. This disparity in the distribution of plastic surgery procedures offered generally holds true across all three countries investigated in this study.

However, a notable exception was observed in Austrian plastic surgery practices, in which procedures belonging to the domains of reconstructive and hand surgery were significantly more commonly offered on their websites compared to German and Swiss practices. While Austrian practices also offer more procedures falling into the domain of burn surgery, this difference did not reach statistical significance. These national variations might highlight differences in the specialization, focus, training and regulatory differences within the field of plastic surgery in Austria compared to Germany and Switzerland.

This discrepancy between the reliance on aesthetic surgery and negligence of the other three pillars of plastic surgery in the practice setting becomes even more apparent when considering the annual data from the American Society of Plastic Surgeons (ASPS): For the United States, which presumably shares similar healthcare and economic dynamics, the 2022 statistics indicate a total of 1,017,003 procedures in Reconstructive, Hand, and Burn surgeries combined, as opposed to 1,498,361 procedures in Aesthetic surgery [11]. In our study, we were able to show that procedures belonging to the aesthetic surgery domain were offered in 98.8% of websites while less than half of the websites analyzed in our websites with 43.8% listed at least one surgical procedure of the remaining plastic surgery pillars. Hence, these numbers indicate a lower availability of reconstructive, hand, and burn surgeries in the practice setting, albeit the demand for these procedures reportedly does not proportionally lag behind. The preference for aesthetic procedures over reconstructive, hand, and burn surgeries potentially not only reflects economic incentives but might also be attributed to the perception of plastic surgery in the practice setting by the general population [12,13,14]. This skewed perception might inadvertently lead to an undervaluation of the potential role plastic surgery can play for restoration and rehabilitation. The disparity unveiled herein underscores the need for a more balanced and well-rounded approach of plastic surgery in the practice setting, ensuring that patients seeking non-aesthetic procedures are not marginalized. Enhancing the accessibility and visibility of non-aesthetic procedures can therefore result in more equitable healthcare access and better address unmet patient needs.

However, according to the study’s findings, patients seeking aesthetic procedures, both surgical and non-surgical, are confronted with a good care situation with 98.8% and 87.9% of all practices included in our analysis offering surgical and non-surgical aesthetic procedures, respectively. In recent times, particularly in demand are procedures yielding natural-looking results with minimal recovery time, often found in non-surgical aesthetic procedures. The most recent trend in this field goes to minimally-invasive, non-surgical preservative procedures rather than surgical, restorative procedures [11, 15]. This is prompting plastic surgeons to constantly develop their procedural repertoire. Whether the current trend towards non-surgical aesthetic procedures will continue and eventually reflect in the procedures offered in plastic surgery practices remains subject to future investigations, for which the present study offers a reference.

Not only were interesting observations made in regard to the procedures offered in the analyzed websites, but also when taking a closer look at the plastic surgeons working in these practices: Swiss plastic surgeons are board-certified for the shortest duration on a statistically significant level, with an average of 16.20 years, compared to 20.20 years and 20.43 years in Germany and Austria, respectively. Additionally, plastic surgery practices located in Switzerland have been shown to operate for a shorter duration, with an average time period of 11.41 years, which is statistically significantly shorter than the 12.99 years and 17.14 years observed in Germany and Austria, respectively. This difference might be attributed to specific factors within each country's professional culture and medical system. An interesting trend is further observed when looking at the average number of procedures offered in each country investigated: German practices, despite having a statistically significant higher number of board-certified plastic surgeons (1.81 per practice), offered fewer procedures (17.89) – as by the procedures defined in the study’s methodology—compared to their Austrian (21.68) and Swiss (20.67) counterparts, thereby suggesting a greater degree of specialization within German plastic surgery practices.

Based on the authors’ experience with websites of plastic surgery practices and on the findings obtained in this study, some tips and tricks can be summarized for the plastic surgeon intending to create an effective and informative website:

  1. i)

    The exhaustive listing of all procedures – both surgical and non-surgical – on the practice website ensures visibility and allows to reach a greater patient audience. We were able to show that non-aesthetic domains of plastic surgery tend to be underrepresented. For plastic surgeons aiming to increase their surgical caseload, additionally offering non-aesthetic procedures would be worth considering to allow for an exhaustive coverage of all plastic surgery domains, ultimately ensuring appropriate patient care in this surgical specialty. The inclusion of lesser known, novel or more specialized procedures can be a distinguishing feature that helps the plastic surgeon to set himself/herself apart from the competition.

  2. ii)

    Regional differences for treatments offered – as outline in this study—should be kept in mind when creating a website. For instance, Swiss and German plastic surgery practices have been shown to list procedures belonging to the reconstructive and hand surgery domain statistically significantly less often when compared to Austrian practices. Therefore, Swiss and German plastic surgeons should consider including such procedures to account for this gap and potentially offer their services in regions where patients might face greater challenges finding appropriate care in the practice setting.

  3. iii)

    Avoiding medical jargon and using easily accessible and clear language is essential for patients to understand the range of services offered, enabling them to form informed medical opinions.

  4. iv)

    Website content should be updated regularly and new procedures, technologies and trends in plastic surgery should be discussed on the website. This not only increases visibility in search engines due to the coverage of novel and commonly searched for topics but also provides the patient with trustable information. It can be assumed that this can help foster the trust between patient and surgeon.

This study, however, is not free of limitations as it relied only on the procedures offered on the websites of the respective plastic surgery practices. These websites may not perfectly reflect actual reality of all procedures performed in the respective practice. Still, they do provide insights into the practice's primary focus and self-image and thus serves as the best available approximation for the scopes of our study. From a business perspective, it is also worth noting that it is advantageous for plastic surgeons to comprehensively and exhaustively list all available procedures to maximize their practice's profitability. Therefore, we have specifically chosen the procedures offered on the websites to learn more about the current trends and procedures of plastic surgery care in the practice setting.

This study provides a snapshot of plastic surgery procedures in the practice setting in German-speaking European countries and lays a foundation for future research employing the same methodology to better understand the evolution of this medical specialty. A particularly interesting outlook would be whether the current trend towards non-surgical aesthetic procedures also reflect in the online presence of plastic surgeons or whether they prefer to stick to their “core business”. Additionally, this study aims to inspire other researchers to conduct similar analyses on a global scale to help gain a broader understanding of regional differences and trends in plastic surgery. Further, such analyses would help to understand the bigger, global picture of the wide field of plastic surgery.

Conclusions

Our study reveals a pronounced focus on aesthetic procedures on plastic surgery practice websites in Germany, Austria and Switzerland, with less emphasis on reconstructive, hand, and burn surgeries. This trend suggests a potential underrepresentation of non-aesthetic procedures in plastic surgery outpatient care. Notably, Austrian plastic surgery practices more often listed procedures falling into the domain of reconstructive and hand surgeries compared to their German and Swiss counterparts, effectively illustrating regional differences within the field. The study also uncovers trends in professional practices, such as the tendency of Swiss plastic surgeons to work in a practice setting sooner after obtaining board certification than German and Austrian plastic surgeons. German plastic surgery practices employed more plastic surgeons per practice while offering a smaller range of procedures, indicating a higher degree of specialization. This study underscores the need for a more well-rounded approach in plastic surgery care in the practice setting, catering to aesthetic and non-aesthetic patient needs.