A fuller editorial guide to breast surgery quality is coming soon. For now, the ranking below compares every country we have assessed on it — open a country's report for the cited detail behind its score.
Epidaurus · Treatment Guide · Aesthetic & Cosmetic Services
Going abroad for —
Breast Surgery Quality
Breast augmentation, reduction, lift, and reconstruction quality
The country comparison
Which countries are best for breast surgery quality
The destinations ranked high→low under this lens — each with the reasoning behind its score, the cited evidence one click down, and its full report. The verdict is free; the report is the depth.
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1
South Korea
KR
5.0/5
Good
South Korea demonstrates exceptional breast surgery quality, comprehensively exceeding Score 5 criteria. The country boasts 2,491 board-certified breast surgeons performing 3-5x more procedures annually than Western c...
Full report
The evidence behind this score 5 cited points
- 2,491 board-certified plastic surgeons trained in breast procedures with all breast surgeons completing 2-year breast surgery fellowships
- Infection rates <2% in accredited facilities versus global average 4-6%; capsular contracture rates 1.79% for Motiva Ergonomix
- Revision surgery rate only 3.2% within 5 years using advanced techniques; 89% maintain breast lift after 5 years
- VECTRA 3D imaging used in 89% of consultations; five premium implant brands available (Motiva, Mentor, SEBBIN, Natrelle, BellaGel)
- 29 JCI-accredited hospitals and 31 medical tourism certified facilities; Korean Breast Implant Registry launched 2020 for systematic outcome tracking
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2
Brazil
BR
4.5/5
Good
Brazil demonstrates exceptional breast surgery capabilities across most dimensions. The country has ~6,700 SBCP-certified surgeons, documented infection rates of 1.2% and capsular contracture rates of 1.7% at elite ce...
Full report
The evidence behind this score 7 cited points
- Surgeon expertise: ~6,700 SBCP-certified plastic surgeons with standardized 5-year postgraduate training (2 years general surgery + 3 years plastic surgery); Ivo Pitanguy Institute trained 600+ surgeons from 42 countries over 60 years [SBCP Homepage - 2024]
- Documented complication rates: Ivo Pitanguy Institute 416-case series shows 1.2% infection, 1.7% capsular contracture, 1.15% overall complication rate—exceeding Score 5 thresholds [Does the Use of Intraoperative Breast Sizers Increase Complication Rates - PubMed/PMC - 2016]
- Surgical techniques: Full spectrum available including fat grafting (54.9% of surgeons), DIEP flap microsurgery at leading centers, oncoplastic reconstruction with 96.4% of trained surgeons mastering contralateral symmetrization [National Survey on Attitudes of Brazilian Breast Surgeons - Annals of Surgical Oncology - 2025]
- Implant availability: All major international brands (Mentor, Allergan, Motiva) plus Silimed (largest in Latin America, FDA/CE/ANVISA approved) [Silimed Our History - 2024]
- Facility accreditation: 25 JCI-accredited hospitals in Brazil; Hospital Moinhos de Vento ranked #1 nationally, Hospital Israelita Albert Einstein in top 30 globally [Brazil's Best Plastic Surgery Clinics 2025 - Newsweek - 2025]
- International patient infrastructure: All-inclusive packages in 6 major cities, 50-65% cost savings vs. USA, dedicated international departments with English/Spanish/Japanese support, 10-14 day recommended stays [Breast Augmentation Abroad - Medical Tourism Brazil - 2024]
- Red flag—quality variance: Unregulated aesthetic market operates alongside certified sector; technovigilance database shows 786 notifications over 16 years for hundreds of thousands of annual procedures, suggesting underreporting [Safety and Performance of Postmarketing Breast Implants - Journal of Clinical Medicine - 2025]
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3
Germany
DE
4.5/5
Good
Germany exceeds most Score 5 criteria with documented evidence: 1,102 board-certified specialists (vs. 50+ required), 248+ accredited facilities (vs. 10+), full range of advanced techniques including microsurgery, all...
Full report
The evidence behind this score 9 cited points
- 1,102 DGPRÄC board-certified specialist surgeons completing mandatory 72-month training, far exceeding Score 5 requirement of 50+ specialists
- 248 DKG-certified breast cancer centers plus 22 specialized microsurgical reconstruction centers with ISO 9001 quality management and independent triennial audits
- Comprehensive advanced techniques documented including DIEP/TRAM/latissimus flaps, robotic-assisted surgery, VASER fat grafting, and dual-plane augmentation
- Access to all major premium implant brands (Mentor, Allergan, Motiva) plus domestic POLYTECH manufacturer with enhanced CE standards
- Documented infection rate of 1.5% for cosmetic breast augmentation, meeting Score 5 threshold of <2%
- DIEP flap reconstruction registry showing 96.9% overall success rate across 4,577 procedures at 22 centers
- Vectra XT 3D imaging at Klinik am Rhein and Crisalix 3D simulation in Munich providing surgical planning at multiple facilities
- Mandatory national breast implant registry (Implantateregister Deutschland) operational since July 2024 with financial penalties for non-compliance
- Dedicated international patient services at major clinics including ETHIANUM Klinik Heidelberg with English-speaking surgical teams and structured recovery programs
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4
Spain
ES
4.5/5
Good
Spain demonstrates excellent breast surgery infrastructure with 900+ board-certified plastic surgeons (far exceeding the 50+ requirement), comprehensive advanced techniques including world-class DIEP reconstruction, p...
Full report
The evidence behind this score 5 cited points
- Surgeon qualifications: 900-1000+ board-certified plastic surgeons through SECPRE; mandatory 5-year MIR residency and September 2024 law restricting cosmetic surgery to MIR-qualified physicians
- Complication rates: SECPRE reports <2% capsular contracture for textured implants; 1-4% infection rates aligned with global best practice
- Technology: DIEP flap expertise pioneered in Barcelona (1% flap loss rate); 3D imaging standard at major centers (Alma3D, Crisalix, VECTRA)
- Facility accreditation: 7 JCI-accredited hospitals (Centro Médico Teknon, Dexeus, Sagrat Cor, Jiménez Díaz, Ruber Internacional, Quirónsalud Marbella, Hospital de Navarra) plus EUSOMA certification for breast cancer; falls short of 10+ threshold
- International services: Comprehensive English-speaking support, dedicated coordinators, all-inclusive packages, Next Day Surgery programs, 30-70% cost savings vs US/UK
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5
United Kingdom
GB
4.5/5
Good
The UK represents world-class breast surgery quality with 1,386+ BAPRAS-registered specialists, comprehensive advanced techniques, all three premium implant brands, 3D imaging as standard, and exceptional regulatory i...
Full report
The evidence behind this score 5 cited points
- Surgeon expertise: 1,386 BAPRAS members on GMC Specialist Register + 350+ BAAPS members + 14 funded oncoplastic fellowship posts — far exceeding Score 5 threshold of 50+
- Technology: Mentor, Allergan, Motiva implants widely available; Crisalix, Vectra, Motiva Imagine 3D imaging standard at leading centres; microsurgical DIEP flaps with AI perforator mapping at multiple NHS/private centres
- Safety infrastructure: Mandatory CQC registration with public ratings (HCA UK: 16 Outstanding + 22 Good); MHRA pharmacovigilance; BCIR national registry at ~80% coverage; BIA-ALCL rate 1 per 12,187 implants
- Outcomes: 99% positive outcomes and 98% recommendation rates for breast augmentation in independent sector; 94% rise in corrective surgeries for abroad-performed procedures demonstrates UK's corrective capacity
- International services: 30,000+ medical tourists in 2022; comprehensive international patient programmes; English-language care; virtual pre-operative consultations; HCA insurance partnerships (Cigna, Blue Cross Blue Shield, International SOS)
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6
United Arab Emirates
AE
4.5/5
Good
The UAE demonstrates exceptional breast surgery capabilities meeting most Score 5 criteria: 236+ board-certified surgeons in Dubai with per-capita density among highest globally; multiple surgeons exceeding 500+ annua...
Full report
The evidence behind this score 5 cited points
- Dubai had 236 DHA-licensed plastic surgeons in 2018 with per-capita density among highest globally; Dr. Sanjay Parashar alone has 2,000+ personal breast augmentation cases
- Cocoona Clinic reports DHA-audited 0.8% overall surgical complication rate across 85,000 procedures (including 4,000+ breast surgeries) with 99.2% patient satisfaction; Dr. McGoldrick reports zero infections in 950+ breast cases
- Comprehensive techniques available: endoscopic transaxillary, fat grafting, robotic-assisted DIEP flap (UAE's first, January 2026), Da Vinci robotic mastectomy, 3D Crisalix imaging, all premium implant brands (Motiva, Mentor, Allergan, Sebbin, Polytech B-Lite)
- 10+ JCI-accredited facilities including King's College Hospital Dubai (first in UAE with SRC Breast Centre of Excellence designation) and Mediclinic City Hospital (JCI Academic Medical Centre with disease-specific breast certification)
- Exceptional international patient infrastructure: 82 countries visa-free/visa-on-arrival; American Hospital serves 100+ nationalities with dedicated coordinators, translation, telemedicine follow-up, English universal in medical settings
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7
Singapore
SG
4.5/5
Good
Singapore demonstrates exceptional breast surgery quality across all major dimensions. The country has 90+ rigorously trained plastic surgeons with international fellowships, documented infection rates of ~1.2% and ca...
Full report
The evidence behind this score 5 cited points
- 90 registered plastic surgeons in 2023, all completing SAB-accredited 72-month training; multiple specialists hold international fellowships in breast reconstruction and aesthetic breast surgery
- Infection rates approximately 1.2% in published series; Motiva nanotextured implant capsular contracture rates below 1% globally, significantly lower than Score 5 threshold of <3%
- Full spectrum of advanced techniques available: DIEP flap, TRAM flap, endoscopic/robotic approaches with 80-90% improved cosmetic outcomes; Preservé minimally invasive technique available at certified clinics
- 23 JCI-accredited hospitals nationally (highest concentration in Asia), exceeding Score 5 threshold of 10+; SGH plastic surgery department runs 2+ dedicated surgical lists daily with 13 surgeons
- Singapore ranks #2 globally in Medical Tourism Index and #1 for Quality of Facilities; 646,000 international patients in 2024; 65% use teleconsultation before travel; comprehensive English-language care and medical concierge services available
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8
Thailand
TH
4.5/5
Good
Thailand demonstrates world-class breast surgery quality across virtually all dimensions: 400+ board-certified specialists far exceed the 50+ threshold, national case volumes (~15,300 annually) with individual surgeon...
Full report
The evidence behind this score 6 cited points
- ThPRS has 400+ certified members and country hosts ~500 aesthetic surgeons nationwide, far exceeding 50+ requirement [Best Plastic Surgeons in Thailand 2026 - Konkai - 2026]
- Approximately 15,300 breast augmentations annually (ISAPS 2023); individual surgeon Dr. Veerawat Tirananmongkol with 5,000+ career breast procedures and four consecutive Motiva Awards [Complete Guide to Breast Augmentation in Thailand - Bookimed - 2025]
- Surgical site infection rate 1.3% with antibiotic prophylaxis, well below 2% threshold; 97%+ procedures without major complications at accredited centers [Evaluation of Preoperative Antibiotic Prophylaxis - PMC - 2024]
- Motiva, Mentor, and Allergan implants all available and TFDA-regulated; all implants in highest-risk device categories under Medical Devices Act [Complete Guide to Breast Augmentation in Thailand - Bookimed - 2025]
- Nine JCI-accredited or equivalent facilities confirmed: Bumrungrad (7 consecutive accreditations since 2002), Samitivej, Yanhee, Vejthani, Kamol, Asia Cosmetic, Chaophya, PPSI, Bangkok Cancer Hospital; 3D imaging standard at leading centers with 1,153-patient RCT at Phramongkutklao improving satisfaction from 7.5 to 9.1/10 [The Role of 3-dimensional Imaging - PMC - 2025]
- International patients constitute 25.4% of aesthetic surgery cases; English-speaking surgeons with international fellowship training; dedicated medical tourism facilitators; telemedicine follow-up for international patients [Aesthetic Plastic Surgery in Bangkok - Contour Clinic Thailand - 2024]
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9
Turkey
TR
4.5/5
Good
Turkey demonstrates excellent breast surgery infrastructure with 46-50 JCI-accredited hospitals, 116 qualified breast augmentation specialists, and leading clinics achieving outstanding outcomes (0.3% infection rate, ...
Full report
The evidence behind this score 5 cited points
- 46-50 JCI-accredited hospitals across Turkey, 21% of all global JCI-accredited clinics, providing rigorous international safety standards
- Leading clinics document 0.3% infection rate and 3.2% capsular contracture over five years, with 92% patient satisfaction across 347 cases
- 116 breast augmentation doctors ranked on Bookimed; surgeons with 150-200+ annual breast cases; Dr. Hasan Şahin performed 12,000+ aesthetic surgeries
- Premium implant brands (Mentor, Motiva, Allergan, Natrelle) available at clinics; 3D Vectra simulation available at premium facilities; microsurgery and fat grafting capabilities documented
- NHS 2023 study documented 20 of 25 corrective surgery patients initially underwent surgery in Turkey with 72% presenting post-operative infection and wound dehiscence complications, demonstrating quality variation across providers
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10
United States
US
4.5/5
Good
The United States demonstrates exceptional breast surgery quality with world-leading surgeon expertise, 250,000+ annual procedures, excellent safety outcomes (<1% infection), comprehensive facility standards (2,000 ac...
Full report
The evidence behind this score 10 cited points
- Board certification: American Board of Plastic Surgery (ABPS) certification requires minimum 6 years surgical training with 3+ years in plastic surgery; ASPS represents 9,000+ members globally
- Surgical volume: 250,000 breast augmentations performed in 2023 alone, with major centers like PRMA performing 1,000+ DIEP flap reconstructions annually with 99%+ success rate
- Infection rates: <1% for primary augmentation (exceeds <2% Score 5 threshold); accredited ambulatory facilities document complication rates <0.5%
- Capsular contracture: 3.6% overall rate (exceeds <3% Score 5 requirement but within 3-5% Score 4 range); variation 2.4-18.9% depending on technique
- Implant access: All FDA-approved premium brands available (Motiva, Allergan, Sientra, Mentor) with latest approvals in late 2024
- Facility accreditation: 2,000 AAAASF-accredited facilities nationwide, far exceeding 10+ requirement
- Revision rates: Approximately 20% require revision within 10 years (exceeds <10% Score 5 threshold and 10-15% Score 4 maximum)
- 3D imaging: 15% adoption rate among surgeons (available but not standard practice; limited compared to Score 5 expectation)
- Long-term follow-up: FDA recommends imaging starting 5-6 years post-op and every 2-3 years thereafter
- Medical tourism: US primarily functions as a sender rather than receiver of medical tourists; limited specialized international patient support infrastructure
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11
Colombia
CO
4.0/5
Good
Colombia demonstrates strong breast surgery capabilities with 850+ board-certified SCCP surgeons, excellent documented infection outcomes (0.38% in breast augmentation), 7 JCI-accredited facilities, and comprehensive ...
Full report
The evidence behind this score 5 cited points
- 850+ SCCP board-certified plastic surgeons with international training and ISAPS affiliation
- 0.38% infection rate in 9,691-case breast augmentation study (far below 2% Score 5 threshold)
- 7 JCI-accredited facilities including 1 exclusive plastic surgery clinic with Gold Seal accreditation
- Premium implant brands (Mentor, Motiva Ergonomix, Allergan) widely available and INVIMA-authorized
- Comprehensive English-language medical tourism infrastructure with dedicated recovery facilities and virtual follow-up care
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12
Malaysia
MY
4.0/5
Good
Malaysia demonstrates strong breast surgery quality infrastructure with 20-49 board-certified plastic surgeons, comprehensive advanced techniques (dual-plane, endoscopic, DIEP flaps), premium implant availability, and...
Full report
The evidence behind this score 6 cited points
- NSR registration mandatory for all specialist plastic surgeons; multiple surgeons with international credentials (FRCSI(Plast), ISAPS membership, fellowship training)
- 8 JCI-accredited hospitals offering breast surgery (meets 5-9 range); Sunway Medical Centre holds JCI, ACHS, and MSQH simultaneously; 123 total MSQH-accredited facilities
- Comprehensive surgical techniques documented: dual-plane, endoscopic transaxillary, fat grafting, DIEP flap microsurgery available
- Premium implants readily available: Motiva Ergonomix, Mentor MemoryGel Xtra, Mentor Contour Profile Gel across multiple clinics
- Excellent international services: 90%+ international patients at Beverly Wilshire, Prince Court serves 140+ countries, 1.52M international health travelers to Malaysia in 2024, multilingual support and virtual follow-up available
- Critical gap: Country-specific published registry data on infection, capsular contracture, and revision rates not publicly available from centralized source
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13
Israel
IL
4.0/5
Good
Israel demonstrates good breast surgery quality with strong surgeon expertise (187 board-certified members, widespread JCI accreditation), comprehensive advanced techniques (microsurgery, 3D imaging, premium implants)...
Full report
The evidence behind this score 5 cited points
- 187 board-certified plastic surgeons with breast surgery focus and 22 public hospital units with 80 residents in training
- Documented infection rates <1% at Herzliya Medical Center for breast augmentation, with B-Lite implant showing 6.3% complication rate across 1,653 implants
- Full spectrum of advanced techniques available: DIEP flap microsurgery, 3D pre-surgical imaging at leading centers, fat grafting, and all premium implant brands (Motiva, Allergan, Mentor)
- Four major JCI-accredited hospitals (Assuta, Tel Aviv Sourasky, Sheba, Rambam) performing breast surgery; Sheba ranked #7 globally (Newsweek 2026)
- Dedicated international patient departments at all major private hospitals with English-language proficiency and comprehensive support services; costs 30-70% below US/UK prices
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14
Japan
JP
4.0/5
Good
Japan demonstrates excellent clinical outcomes and exceptional surgeon expertise with 3,200+ certified plastic surgeons and documented infection rates of 0.9-1.9% and capsular contracture of 1.1-2.2% at certified faci...
Full report
The evidence behind this score 5 cited points
- Surgeon expertise: 3,200 JSPRS board-certified plastic surgeons with breast surgery specialization; TCB Tokyo Central Beauty Clinic surgeons report 1,000+ annual breast augmentation cases [JSPRS Background - 2024]
- Complication rates: Infection 0.9-1.9%, capsular contracture 1.1-2.2% at JOBSS-certified hospitals (2020-2022 data) [Current Status of IBR in Japan - Ishii et al. - Gland Surgery - 2024]
- Facility standards: 5-6 JCI-accredited hospitals identified including St. Luke's International Hospital, Saitama Medical University International Medical Center, and Fujita Health University Hospital [JCI Accreditation sources - 2024]
- Technology: Japan pioneered CAL fat-grafting technique; comprehensive techniques including DIEP flap, hybrid augmentation, and 3D imaging available [Cell-Assisted Lipotransfer - Yoshimura et al. - PMC - 2008]
- Quality concern: Consumer complaints surged from 2,200 (2020) to 17,000 (2024) correlated with budget clinic chain expansion [Is Cosmetic Surgery Safe in Japan - ClinicJapan.net - 2026]
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15
Jordan
JO
3.5/5
Moderate
Jordan demonstrates strong breast surgery capabilities through internationally trained surgeons (20+ specialists with US/UK credentials), comprehensive surgical techniques including microsurgical reconstruction, and 5...
Full report
The evidence behind this score 5 cited points
- 60 board-certified plastic surgeons nationally, 20+ in Amman offering breast procedures, including surgeons with US/UK board certification and international fellowship training at Cleveland Clinic, AUB, and UT Southwestern
- Full-spectrum surgical techniques available including DIEP flap microsurgical reconstruction, multiple implant options, 3D imaging at leading clinics, and comprehensive post-operative care protocols
- 5 JCI/HCAC-accredited hospitals with dedicated plastic surgery departments (Abdali, Specialty, Al Khalidi, Arab Medical Center, KHCC) subject to regular quality audits
- No published national statistics on infection rates, capsular contracture rates, or revision rates—critical transparency gap for medical tourists despite hospital audits of outcomes
- Well-developed international patient infrastructure with 235,000+ medical tourists in 2025, medical visa program, English-speaking specialists at accredited facilities, and 25-40% cost savings versus Western prices
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16
Mexico
MX
3.5/5
Moderate
Mexico demonstrates strong breast surgery capability at accredited facilities with 95%+ patient satisfaction, multiple JCI-certified hospitals, advanced microsurgical techniques (DIEP flap, dual plane), and premium im...
Full report
The evidence behind this score 6 cited points
- 95%+ patient satisfaction at certified facilities matching US/Canadian outcomes
- Multiple JCI-accredited facilities: Hospital Puerta de Hierro (Guadalajara), Galenia Hospital (Cancun), Riviera Institute
- Advanced surgical techniques available including DIEP flap microsurgery, dual plane implant placement, and fat grafting
- Top surgeons documented: Dr. Joaquin Ayala Del Muro with 7,000+ breast augmentations over 33 years with zero complications
- Premium implant brands readily available: Motiva, Mentor, Nagor, Eurosilicone, Polytech
- Comprehensive international patient support with bilingual staff, all-inclusive packages, and daily post-operative hotel care
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17
Poland
PL
3.5/5
Moderate
Poland demonstrates strong capabilities for cosmetic breast procedures with 282 board-certified surgeons, excellent complication rates (1-2% infection, <1% capsular contracture for modern implants), and all major prem...
Full report
The evidence behind this score 5 cited points
- 282 board-certified plastic surgeons with majority in private aesthetic practice, exceeding Score 5 threshold of 50+ [Plastic Surgery in Poland—Should We be Concerned? - PMC - 2025]
- Complication rates of 1-2% infection and <1% capsular contracture for nanotextured/polyurethane implants, below international thresholds [Breast Augmentation in Warsaw, Poland - Dr Zykov - 2024]
- All major premium implant brands (Mentor, Motiva, Polytech, Allergan, Nagor, Eurosilicone, Sebbin) available under EU MDR compliance [Medical Devices and In Vitro Medical Devices Regulations - European Parliament - 2024]
- Zero JCI-accredited facilities for plastic or breast surgery, and no EUSOMA-certified breast cancer centres [Breast Surgery: Closing the Quality Gap in Poland - Cancer World Magazine - 2024]
- Microsurgical reconstruction capability limited to only ~1/3 of plastic surgery departments; 18% of mastectomies receive immediate reconstruction vs 60-80% in Western Europe [Landscape of Oncoplastic Breast Surgery across Poland - PubMed - 2018]
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18
Hungary
HU
3.5/5
Moderate
Hungary demonstrates solid surgeon expertise with internationally credentialed specialists and a comprehensive range of breast surgery techniques including DIEP flap microsurgery and oncoplastic procedures. EU-regulat...
Full report
The evidence behind this score 7 cited points
- Dr. Ottó Kelemen: 32+ years specialized plastic surgery with ISAPS/IPRAS/international society memberships; Dr. Gergely Pataki presented at ISAPS 2024 World Congress on breast surgery; Dr. Zsolt László: IPRAS member, Semmelweis University trained
- Full-spectrum procedures available: DIEP/TRAM flap microsurgery, fat grafting, oncoplastic surgery, dual-plane augmentation at multiple Budapest facilities
- Premium implant brands (Mentor, Allergan, Motiva, Polytech) all CE-marked under EU MDR with identical safety standards as Western Europe
- Only 1 JCI-accredited facility confirmed (Aesthetica Medical Center) vs. 5–9 required for Score 4; multiple ISO 9001 certifications present
- No Hungary-specific outcome registry published; no documented Hungary-specific infection rates, capsular contracture percentages, or revision rates; reliance on global implant manufacturer data rather than surgical facility data
- Semmelweis University study found 87.5% of Hungarian breast cancer patients had minimal/no knowledge about reconstruction options—systemic patient counseling gap in oncoplastic services
- Well-developed international patient infrastructure: English-speaking staff, telemedicine follow-up to 12 months, 50–70% cost savings vs. Western Europe
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19
India
IN
2.5/5
Moderate
India demonstrates strong surgical infrastructure with advanced techniques and internationally accredited facilities, but critical infection control deficiencies substantially limit quality. Breast surgery infection r...
Full report
The evidence behind this score 5 cited points
- Breast surgery infection rate 8.3% per INICC data versus 1.7% international standard and 2.3% CDC-NHSN—critical patient safety concern exceeding Score 3 threshold of 4-6%
- Advanced surgical techniques available including DIEP/SIEA flaps, LD flaps, and fat grafting; premium implant brands (Allergan, Mentor, Sientra) accessible at major facilities
- Multiple JCI/NABH-accredited hospitals (Apollo, Ganga Hospital, Aster Medcity) with internationally trained surgeons; fellowship programs at major institutions
- No published India-specific outcome data on capsular contracture, revision rates, or case volumes; report explicitly states this data 'not readily available in published literature'
- 3D imaging for surgical planning not standard practice—limited availability only; training in breast surgery 'highly variable, evolving slowly and needs to be structured urgently'