‘A flaw in the legislation means any medical graduate can call themselves a cosmetic surgeon’


Plastic surgeons have criticised cosmetic surgeons and beauty clinics operating without a doctor present, following the case of a Sydney woman becoming blind in one eye last month after being injected with dermal fillers.

We speak to Sydney plastic surgeon Dr Ross Farhadieh, who talks about the recent horror stories he has seen when cosmetic procedures go wrong.

Q: How is it that a cosmetic filler injection, a fairly minor procedure, could lead to blindness?

A: The first reported case of someone going blind as a result of filler injections dates back about 50 years. It’s not the filler, however, that causes the blindness but the hydrocortisone suspension being injected into the scalp.

The particulate matter goes against the arterial flow, so when pushed in too hard the hydrocortisone ends up in the retina. Injections in the nose, side tips of the nose, and around the eyes and cheeks are the danger areas.

This case highlights what should have happened after the cosmetic surgeon knew the woman was at risk, because there is a 60- to 90-minute window to stop the patient going blind. If well-trained, the surgeon should be in a position to save the patient from blindness.

But the vast majority of clinics in Australia are run by nurses, and doctors consult through Skype — or haven’t been trained appropriately. This does potentially put patients at an increased level of risk, should something rare like this happen.

Q: What kind of problems do you see resulting from cosmetic surgery?

A: I see a lot of cases that are revision surgeries. In recent months I have seen a handful of patients who’ve come back from Thailand, where they underwent cosmetic surgery.

One of the patients had extensive liposuction and a tummy tuck, and her belly button was about 5cm off-centre when she woke up from the surgery. She also ended up with some burns because the liposuction had been done with an ultrasonic machine, which can burn the skin.

The liposuction had also created a cavity between the abdominal wall, the skin and fat, which filled with fluid and made her look like she was pregnant. The shape was all wrong. We re-operated to fix everything.

Q: What are some other, more common revision surgeries you routinely do?

A: Women who had breast implants have required revision surgery to fix something called a ‘double bubble’ deformity, where the breast mound sits separate to the implant.

Quite a few of the patients have also required surgery for infected fillers either in the lower eyelid, or from face fillers. A biofilm develops and no amount of antibiotics will penetrate it. Instead, the biofilm must be scraped out very carefully.

Q: You believe major invasive cosmetic surgery should only be carried out by surgical fellows. Why do you believe regulators allow these procedures to be done by other doctors?

A: A flaw in the legislation means any medical graduate can call themselves a cosmetic surgeon. They could’ve done a couple of weekend courses and then pitch up and call themselves a cosmetic surgeon.

Also when it comes to aesthetic surgery, there’s no Medicare item number, so therefore doctors can also call themselves cosmetic surgeons — and do whatever procedure they want.

To be truthful, these doctors are not surgeons. Even if a handful have gone through the cosmetic college that was recently set up (the Australasian College of Cosmetic Surgery and its Surgical Registrar Training program) and passed the exam, they still cannot call themselves a surgeon. They’re basically using this legal loophole to do things they’re not qualified to do.

Q: Isn’t it just a turf war between cosmetic and plastic surgeons, given the lucrative business that can be generated?

A: We have enough work to do — most plastic surgeons I know are not in any desperate need to take on more patients. This issue is about the level of training a doctor has had. It starts with the recognition of these professional bodies we have set in place, where there are conservative and rigorous steps involved to make sure a patient’s welfare is put first, and internal self-regulatory monitors to make sure we’re trained properly.

Q: Isn’t the idea of a plastic surgeon doing cosmetic surgery a waste of their training, given the demand for reconstructive plastic surgeons?

A: I do both — head and neck reconstruction from trauma, reconstructive surgery, teaching at a public hospital, as well as aesthetic surgery in the private setting. At the end of the day, you can’t be a good aesthetic surgeon if you don’t have a very good understanding of reconstructive surgery. I could never just perform cosmetic surgery, I’m very happy with the mix that I have. I find the reconstructive surgery helps me with my aesthetic surgery — and vice versa.

Q: Are there particular cosmetic surgical procedures you won’t do?

A: I will not do a so-called Brazilian butt lift. I don’t consider it a safe or reliable procedure. Despite its popularity, it continues to have a very high mortality rate of one in 3000. In all the cases analysed of where people have died, it’s been due to a fat embolism, something rarely seen in aesthetic surgery. We usually only see this complication in major orthopaedic trauma surgery.

It’s thought with this procedure, when they inject fat into the buttocks, it enters the big gluteal veins — and that results in the fat embolism.

None of the professional bodies have so far said this procedure shouldn’t be done but they warn it carries a higher risk profile and we need to recognise that it may not be worth the grief that it might cause.

Q: Is there much evidence on the psychological outcomes of, say, facelifts — are people happier than before?

A: There is evidence, but the important thing is to choose the patient appropriately. A person with body dysmorphic disorder is never going to be happy irrespective of whatever procedure they’re going to have done.

With facelift surgery, the population base is generally a little bit older. They’re generally well-educated and have enough life experience and have reflected on what it is they want, and understand the process — they recognise this surgery is not going to transform their life.

But there is no objective data; all of the stuff is anecdotal, qualitative survey data which are probably not as reliable in this setting because these patients are self-selected.


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