Cosmetic surgery not all prettty

CHOICE investigates the cosmetic surgery industry and uncovers some disturbingly unprofessional practices.
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01 .Cosmetic surgery investigation

Surgery marking illustration

In brief

  • The difference between a plastic surgeon and a cosmetic surgeon can be up to eight years of specialist training.
  • The cosmetic surgery industry is largely unregulated, so how do you work out who is most suitable for your needs?
  • There were some important questions that some cosmetic surgeons did not ask our shadow shoppers, which are critical to ensure the patient’s safety.

Among the latest promotions for cosmetic surgery procedures are “Need a lift?” and “Beautiful breasts always get noticed!”. From print ads and radio spots to glossy magazines dedicated to promoting the latest surgical techniques, cosmetic surgery has never been more in our faces – and the industry is growing at a rapid rate.

Although no formal statistics have been collected on the number of procedures taking place in Australia, experts estimate more than 1000 practitioners perform cosmetic procedures regularly. Popular as it is, however, cosmetic surgery is far less regulated than other areas of medicine – and as CHOICE discovered, some surgeons seem to be getting away all too easily with some alarmingly unprofessional conduct.

Please note: this information was current as of February 2009 but is still a useful guide today.

CHOICE's investigation

To find out how some cosmetic surgery clinics operate, CHOICE recruited three women as shadow shoppers. They visited cosmetic surgery clinics in Sydney and Brisbane, requesting consultations for breast augmentation, liposuction and Botox, and reported back on their experiences. We then formally invited members of the Australian Society of Plastic Surgeons (ASPS) to give expert opinions on how these consultations were conducted.

Who's who of the cosmetic surgery industry

  • Australian Society of Plastic Surgeons (ASPS) This is a not-for-profit membership organisation representing plastic surgeons in Australia. Plastic surgery incorporates both reconstructive and cosmetic surgery. Members must be Fellows of the Royal Australasian College of Surgeons (FRACS), have completed specialist surgeon training in plastic surgery and must adhere to a strict code of ethics.
  • Australasian College of Cosmetic Surgery (ACCS) Previously, to enter the field of cosmetic surgery a medical practitioner would have to do so on an apprenticeship basis (not subject to any quality controls), resulting in varying quality of results. The ACCS was set up in 1999 to fill the gap in differences in quality of cosmetic surgeons, and has an accrediting medical faculty although it is not recognised specialist training.
  • Fellow of the Royal Australasian College of Surgeons (FRACS) This training is recognised by the Australian Medical Council, which is authorised by the federal government to certify medical training.

CHOICE verdict

Considering how easily a doctor can open and operate a cosmetic surgery without specialist training, if you choose to go to a cosmetic surgeon, you need to be clear that you may not be seeing a specialist in the field. At the very least, make sure he or she is a member of the Australasian College of Cosmetic Surgery.

As there is no industry regulation, unfortunately it is still up to consumers to assess the cosmetic surgeon and clinic after asking questions and doing their own research. A potential patient should always check the qualifications and experience of the cosmetic surgeon, as well as the number of surgical procedures he or she has performed, before deciding to go under the knife.

Given the risks if a cosmetic procedure goes wrong, CHOICE would like to see more regulation of this industry to protect consumers.


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Regulation of the industry

While most practitioners regularly describe themselves as either plastic surgeons or cosmetic surgeons, in some cases the difference can be up to eight years of additional training for plastic surgeons. Despite the popularity of cosmetic procedures and increasing competitiveness of the industry, in Australia there is no regulatory body. Instead, there is a range of medical colleges and associations all claiming to offer training and qualifications for doctors providing a range of cosmetic procedures.

Currently, any medical doctor or specialist can perform cosmetic procedures, as it is not recognised as a medical specialty by the Australian Medical Council. However plastic surgery is recognised as a specialty, and members of the Australian Society of Plastic Surgeons are highly trained, members also of the Royal College of Surgeons, and perform both reconstructive and cosmetic procedures. The non-regulation of this growing area of cosmetic medicine is compounded by profuse marketing, following the legalisation of advertising for medical practitioners in 1994.

In 1999, the NSW government commissioned an inquiry into the cosmetic surgery arena; 10 years later, most of the subsequent key recommendations have still not been implemented.

Who should I choose?

In this fiercely competitive industry, CHOICE discovered intense rivalry between the two main industry associations, the Australian Society of Plastic Surgeons (ASPS) and the Australasian College of Cosmetic Surgery (ACCS). Both vehemently put their case to us, but it is up to consumers to decide which is the best option for them. Plastic surgeons undertake a minimum of seven years of additional training once they have obtained their medical degree and most likely become members of the ASPS, which provides specific guidelines to which practitioners must adhere.

Plastic surgeons are also Fellows of the Royal Australasian College of Surgeons, which awards them the status of specialist. The ASPS claims many doctors without specialist training are doing complex cosmetic surgery procedures and advertising themselves as leaders in their field. ASPS President Dr Howard Webster says there is nothing illegal about a GP undertaking surgical work so long as they disclose that information to the patient, but stresses the benefits of specialist training. ”If you train in a certain area then you should probably work in that area. You would probably use an orthopaedic surgeon to do hip surgery on you instead of a GP.”

Cosmetic surgeons The Australasian College of Cosmetic Surgery (ACCS) was established in 1999, stating that its purpose is to fill a gap by providing training and representation for a range of doctors with varying qualifications who have an interest in cosmetic surgery. To qualify as a Fellow of the ACCS, members must be “at least five years postgraduate” and have worked for a minimum of three years in a surgical environment. The college then provides two years of specialist training, and members are audited annually. ACCS President Dr Daniel Fleming argues that “cosmetic surgery is already an area of specialised practice and the only area of medicine practised by a range of doctors from diverse specialty groups from GPs, dermatologists to ear nose and throat specialists, all of whom are united by the fact they conduct cosmetic medical practice”.

In late 2008 the ACCS announced it would be mandatory for its members to disclose how many times they had performed a particular procedure at the initial consultation, if fewer than 100 times. It is also awaiting a decision on an application it made in 2007 to the Australian Medical Council to have cosmetic surgery recognised as a medical specialty. In the meantime there have been a few small positive developments for consumers, with the Victorian government banning “before” and “after” photographs in advertising, while in Queensland the term “surgeon” can only be used by Fellows of the Royal Australasian College of Surgeons. While both major industry associations (ASPS and ACCS) have their own guidelines, as does the NSW Medical Board, these are not enforceable.

Update: Draft code for Australasian College of Cosmetic Surgery rejected by ACCC

Since our initial research, the Australian Competition and Consumer Commission (ACCC) has signalled it will deny authorisation for a code of practice and bylaws developed by the ACCS. In its draft determination the ACCC says it has concerns that a number of clauses in the College's code are not effective.

The ACCC says that it considers that the code in its current form is underdeveloped, and encourages the College to further develop the code with a view to addressing the concerns raised which include transparency for external appeals, a robust and well promoted complaints process and for members to provide sufficient information to patients regarding qualifications, credentials and experience.

The ACCS has 3 weeks to re-submit this application and has indicated that it is willing to work with the ACCC to further develop the code.

Breast augmentation

Breast augmentationBreast augmentation is one of the most popular cosmetic procedures, as well as one of the most emotive. Our shadow shopper visited 12 clinics and uncovered some appalling examples of unprofessional behaviour, including:

  • Being shown the breasts of one of the sales consultants as an example of the doctor’s work.
  • Being told by one doctor that she “needed” to have the surgery done.
  • Being offered a discount if she agreed to have “before” and “after” photos of her breasts published on the internet.
  • Even being told that if she had her breasts enlarged it would increase her chances of finding a partner!

All this aside, our ASPS experts rated overall explanation of the procedure’s potential risks as particularly bad. Our shadow shopper was not totally informed by the doctors about dangers such as haematoma, infection, leakage or scarring.
Some did not even ask why she was considering the treatment. Only seven checked her weight, while only two clinics provided evidence of accreditation when asked (another had a certificate in the waiting room).

In a few instances our shadow shopper also felt she was being pushed into making a decision, and three times was offered brochures about credit without asking (see Change now, pay later, below).


LiposuctionLiposuction is another popular procedure, but also one of the most dangerous. In February 2008, a young Adelaide woman died after having liposuction, as did a Melbourne woman in 2007. Liposuction usually involves pumping the “problem” area with liquid before sucking fat out of the body. It can be painful and requires a high level of post-operative care.

Our shadow shopper was rated by ASPS experts as a poor candidate for liposuction – they suggested she would need to lose weight first and that an abdominoplasty (tummy tuck) would probably be more suitable. She visited 14 cosmetic surgery clinics, and while our experts felt some of her consultations were reasonable, as some cosmetic surgeons suggested abdominoplasty by a plastic surgeon, most also suggested she consider having liposuction in other areas of her body.

One doctor suggested other cosmetic procedures to improve her appearance, such as removing fat from her chin and another doctor suggested removing some moles and skin tags, even though she didn’t request them.

While the general advice about liposuction was sound, not all the doctors said how many surgeries they had performed – and even when they did it was very vague. Very few doctors mentioned their actual qualifications and accreditations, hence placing the onus on the patient to do all the asking.


Botox doesn’t involve surgery and nowadays seems an everyday treatment, even on offer at so-called “Botox parties” held in private homes. Despite this image, it is still a risky procedure and not suitable for all candidates.

BotoxIt’s also critical that potential clients are questioned thoroughly before undertaking the treatment, particularly if there is a possibility the patient is pregnant – an Australian baby was born with severe defects possibly as a result of the mother using a virtually identical treatment to Botox in her first week of pregnancy.

Our ASPS experts didn’t consider the shadow shopper a suitable candidate for Botox and suggested other alternatives would work better for the deep line on her forehead. She visited 12 cosmetic clinics and received varying advice.

One doctor said Botox would not be suitable as she would be unable to use her eyebrows to express herself, instead recommending a filler, which our experts felt was reasonable advice. However, nine doctors recommended both a filler and Botox. Six recommended a brow lift (along with Botox or a filler), which the experts considered reasonable.

While most of the advice she received was acceptable, discussion of risks in all the consultations was minimal. The amount and location of the injections varied widely between consultations. Our experts assessed that one doctor would be injecting in the wrong area of the face, while another told the shadow shopper that Botox wouldn’t fix her problem, yet offered the service anyway.

Shadow shop results concerning

Overall, the results of our shadow shop are concerning. Without discussing risks, it’s extremely difficult for a potential patient to make an informed decision. There were also some important questions that some cosmetic surgeons did not ask the shadow shoppers, which are critical to ensure the patient’s safety.

Some of the shadow shoppers also said they felt rushed through their consultations, and that some practitioners lost interest quickly when it became clear they weren’t a suitable candidate for a procedure. One doctor even took phone calls to arrange a golf game during a consultation!

Change now, pay later

Cosmetic surgery can be very expensive, and is not covered by Medicare or many private health insurers if it is being undertaken for aesthetic reasons only.

A number of finance companies and brokers are targeting potential cosmetic surgery patients with expensive loan offers. So if you’re in a hurry to have a procedure done, perhaps you’re thinking a loan is the answer? Perhaps not. Cosmetic surgery loans can be far more expensive than a low-rate credit card. Mediplan charges an interest rate of 16.9% for members and 17.9% for non-members, including a 7% processing fee (up to a maximum of $295). For an operation costing $4000, the fee would be $280.

Both the Australian Society of Plastic Surgeons and Consumer Action Law Centre (CALC) are critical of these schemes. “If you buy a car on finance, if you can’t afford the repayments at least you might be able to give it back to help pay your debt,” says Carolyn Bond from the CALC. “But what do you do with a breast implant?”.

Questions to ask

Before you arrive at a consultation it’s important to be prepared. Take a list of questions to ask the doctor. Below are some examples.

  • What are your qualifications and experience?
  • How many times have you performed the procedure?
  • How many times have you performed it in the past six months?
  • Can I speak to previous patients?
  • Are there any complications associated with the procedure?
  • If complications do occur or the procedure is not successful, how will you deal with this?
  • Where will the surgery be performed?
  • Will a qualified anaesthetist administer the anaesthetic and/or sedative medication?
  • Will I need time off work?
  • Are there other post-operative side-effects?
  • Will there be any visible scarring following the procedure? How can this be minimised?
  • What aftercare will be provided and will this be included in the treatment costs?

‘Everyone’s reaction is different’

ReactionWhen Kay from Queensland started developing slight jowls at the age of 36, she decided to try a cosmetic procedure. She began to research her options but found information provided by the colleges and organisations too overwhelming. She then investigated the website of a cosmetic surgeon who regularly advertises in the newspaper.

Happy with the information she found, Kay made an appointment with the doctor to discuss her options. He suggested a threadlift, which was described as less invasive than a facelift and involved pulling back sagging skin via a series of small threads attached under the skin.

Kay was quoted $5000 for the work and decided to go ahead with it despite her disappointment with the doctor’s manner. “I would have liked a more personal connection. It was very much like he was thinking ‘just show me the money’.” Despite being told the procedure was minimally invasive, Kay was alarmed by how much swelling developed afterwards. When she returned to the doctor she found him dismissive, saying only that “everyone’s reaction is different”.

Three years later, Kay says she is very unhappy with the results. “I have noticeable skin folds behind my ears, which the doctor told me would settle down, and every now and then I have a ‘pinging’ sensation in my temple, possibly as a result of one of the threads retracting. But I don’t want to go back to a doctor who will just tell me it’s a reaction and everyone is different. I thought the whole thing would be seamless and unnoticeable, but that hasn’t been the case.”

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