The Looks Department
The Rise of Cosmetic Medicine
Illustration by Jeff Fisher.
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Dr Joseph Ajaka came to the world of cosmetic medicine in 2006 after the messy rupture of his training to become an anaesthetist. After five years of specialist training, Ajaka was on the verge of sitting for the final exam. But a personal spat with a senior anaesthetist prevented him from engaging in a critical ‘practice viva’. “I was sick of being treated like shit,” says Ajaka. He thought: “There had to be a better life than this, than the crappy public hospital system.”
He changed out of his freshly cleaned scrubs, flung them away and began storming out of the hospital. But a nurse, noticing his anger, stopped Ajaka and encouraged him to try something different. He was struck by her wrinkle-free skin. “She was Botoxed to the hilt,” he recalls. The nurse suggested that Ajaka consider cosmetics. She worried that his personality and talent for salesmanship would be wasted in the technical role of a medical specialist.
Ajaka’s rage against the medical establishment led him on a new journey to become one of Australia’s most successful cosmetic physicians. From Botox to tummy tucks, lip-enhancement, breast implants and liposuction, his foray into what was then a virtually unknown parallel world bloomed into an empire comprising multiple clinics, with Ajaka as the face of the industry.
Little did he know that he would be part of a growing trend of doctors disillusioned with the system, falling by the wayside or rejecting the extraordinary commitment of specialisation. Cosmetic medicine required only days of training. There was no need to be chained to Medicare and its payment system that had barely kept up with inflation for the past 20 years. If you could sell the treatments and put clients at ease, a burgeoning market of consumers seeking aesthetic self-improvement was happy to part with $600 for 15-minute Botox treatments.
What’s more, cosmetic physicians can earn in the seven figures. “Like it or not,” says Ajaka, “a man is judged by the money he earns and a woman by the way she looks.”
For Dr Rachel Dalli, who had commenced training to become a surgeon, her realisation came in 2004 as she encountered women in senior surgical positions who felt lonely and trapped. “Most of the women didn’t have children, couldn’t hold down a relationship and seemed miserable,” Dalli says.
She met some colleagues who were working in cosmetics and loved their work. “I want to be like that,” she thought. Like many doctors, she confused cosmetic physicians with plastic surgeons. But cosmetics was not among the traditional array of specialties offered within the medical spectrum. Its lack of recognition by medical gatekeepers also meant that the field had virtually no oversight or credentialling requirements.
Cosmetics was part of a broader trend in medicine away from the traditional model of professionally sanctioned procedures, reimbursed by Medicare, toward a simple fee-for-service arrangement. Dalli is relieved that she entered the industry several years ago; today, the growing influx of young doctors seeking a better work–life balance means that competition is fierce.
There is now an army of specialists undertaking extra training in cosmetics, aiming to conduct a lucrative practice on the side of their core specialty or attempting to incorporate procedures, such as Botox, into more traditional work. An eye surgeon might notice sagging eyelids and offer ‘blepharoplasty’ to remove the droop. Gynaecologists sometimes offer procedures to rejuvenate damaged vaginas after incontinence surgery.
Dentists sometimes give their patients Botox injections and lip enhancements, despite the regulations of the Dental Board of Australia stipulating that the procedures only be used to treat dental problems. Dr Myles Holt, who heads the Australian Academy of Dento-Facial Aesthetics (“dedicated to advancing the art and science of aesthetic dentistry”), says he has trained hundreds of dentists to modify lips, cheeks, foreheads and gums. Holt says that the dental board’s view is archaic and “completely at odds with international trends. Dentists have a superior knowledge of facial anatomy and patients are very satisfied with extra procedures designed for aesthetics.”
“The industry is booming,” says obstetrician and gynaecologist Dr Ray Hodgson. On one level of his practice in regional New South Wales, Hodgson sees women with gynaecological problems, while on another he oversees a cosmetic practice – a business he began with his ex-wife, a nurse. Hodgson says that low-income earners are just as likely to present as higher earners. Indeed, a 2005 study in the United States found that 70% of consumers who underwent cosmetic procedures earned less than US$60,000 per year. “There is virtually no stigma anymore,” says Hodgson.
People who used to cower in seclusion until their stitches healed now proudly display their post-operative scars at dinner parties. In 2009 Australians had more than 70,000 non-invasive or minimally invasive cosmetic treatments. The following year we collectively spent $560 million – 25% more than in 2009. That makes us the highest spenders per capita in the world on non-surgical cosmetic procedures.
There is a smorgasbord of options available to any interested customer but Botox dominates and drives the sector. Nurses are allowed to administer treatments such as Botox only if supervised by a doctor. In reality, nurses or even beauticians often perform the procedure, getting a doctor to approve a prescription of botulinum toxin over the phone.
The combination of an exploding consumer demand with a lack of regulation is occurring at an uneasy time in medicine, particularly for those entering or still training within the profession. The past decade has seen the number of medical students in Australia triple, in response to the marked shortage of doctors in regional and outer metropolitan areas. In 2006 Australia had 1335 medical graduates (not including international students) and this number is set to jump to 3108 in 2014, particularly as new medical schools come online. The attraction of alternative career paths, given the arduous nature of specialist training, will only increase.
While critics denounce cosmetic medicine as an expression of our society’s worst impulses, proponents such as Ajaka praise its ability to change lives. “I see it as a kind of positive medicine, instead of treating only people who are sick,” he says. His views are in keeping with the growth of the concept of ‘wellness’, a trend that originated in the 1960s as part of a movement to shift the focus of medicine away from treating disease towards enhancing or ‘adding value’ to the otherwise healthy.
“We exist between beauticians and plastic surgeons,” says cosmetic physician Dr Neal Hamilton, a relative veteran in the industry with two decades of experience.
Hamilton does not see any great urgency to better regulate the industry, commenting that complications arising from cosmetic procedures are rarely more severe than simple scars or mild burns. In his surgery in Sydney’s inner-west, flowing corridors lead to various lounges for resting after procedures, with oil burners spreading aromas of the rainforest or lemon trees. There is also a secret exit.
Dalli is more circumspect about the need for regulation, relating some horror cases, including a woman who ended up in intensive care after receiving an incorrectly administered high dose of Botox. The active chemical acts to paralyse muscles and has sometimes suppressed respiration after being incorrectly injected around the neck or chin. There are regular cases of facial paralysis from Botox, and nerve paralysis from lip treatments is increasing.
The industry of cosmetic medicine has accelerated a new field in the study of emotion, ‘embodied cognition’, which posits that all our cognitive processes are rooted in, and reflected in, the body. Proponents of embodied cognition point to growing evidence that an inability to fully exhibit facial expressions inhibits our capacity to feel the usual range of emotions.
Medical historian Arthur Weston predicts that within two decades there will be more cosmetic surgeries than all other surgical procedures combined. No wonder Ajaka is philosophical about his future. “My first supervisor used to tell me that I was no better than a hairdresser,” he says, emitting a brief giggle. “But hairdressers know how to talk to women. Most doctors don’t. Reminding myself that I’m much like a hairdresser has done wonders for my business.”