BLINDED BY BEAUTY

We’re plump­ing and paralysing our faces for per­fec­tion in rapidly in­creas­ing num­bers as ap­pear­ance medicine goes main­stream – but the in­dus­try’s risky side is emerg­ing, too. Donna-marie Lever in­ves­ti­gates.

North & South - - Cover Story -

Within min­utes of the nurse pierc­ing her skin, there was pain. Then the pa­tient’s face be­gan to change.

The 44-year-old Auck­land woman had just had der­mal filler in­jected near her nose to plump up the bridge and en­hance its shape. Al­most im­me­di­ately, her nose and the skin be­tween her eye­brows red­dened then turned pur­ple, and the vi­sion in her right eye be­came blurry. She was rushed to Auck­land City Hos­pi­tal’s emer­gency de­part­ment.

There, doc­tors were per­plexed and – ac­cord­ing to a spe­cial­ist spo­ken to by North & South – ill-equipped to deal with what was a rare com­pli­ca­tion. What they didn’t re­alise was the woman was rapidly de­vel­op­ing a ma­jor vas­cu­lar oc­clu­sion, or block­age, with a clot ob­struct­ing vi­tal blood sup­ply to her retina.

In­ject­ing filler near the nose, among the maze of blood ves­sels that lie un­der our fa­cial skin, car­ries Rus­sian roulette-style dan­gers. Hit a blood ves­sel that feeds di­rectly to the eye and you risk caus­ing cat­a­strophic dam­age. Once filler en­ters that crit­i­cal vein, there’s a win­dow of just 90 min­utes be­fore ir­re­versible reti­nal cell death oc­curs.

It took three-and-a-half hours be­fore the woman was fi­nally in the right hands – those of ocu­lo­plas­tic sur­geon and oph­thal­mol­o­gist Dr Paul Rosser at Auck­land DHB’S Green­lane Clin­i­cal Cen­tre. He is one of a hand­ful of spe­cial­ists in New Zealand who knows how to han­dle this sort of emer­gency – and, more im­por­tantly, knows what sort of emer­gency it is. But in this case, it was too late. The filler had starved the woman’s eye of blood and oxy­gen sup­ply, caus­ing per­ma­nent dam­age and leav­ing her clin­i­cally blind in one eye.

Work­ing as quickly as pos­si­ble, Rosser had im­me­di­ately given the woman two in­jec­tions di­rectly be­hind the eye of hyaluronidase (orHyalase), a pre­scrip­tion medicine that works like

an “undo” but­ton to dis­solve filler. “Within the first 24 hours... if some­thing is go­ing to help, it will help very quickly,” he says. “In this case, it didn’t. We then put her in hos­pi­tal and gave her IV steroids in case it was swelling that could be re­duced, but those were all just hopes. After that didn’t help, we knew pretty quickly... She was up­set, re­ally up­set, dev­as­tated to lose vi­sion in her eye.”

In fact, when a pro­ce­dure like this goes wrong, no one knows if us­ing hyaluronidase to pre­vent per­ma­nent dam­age to the eye is a treat­ment that ac­tu­ally works. In a 2015 in­ter­na­tional study that looked at around 100 cases of blind­ness caused by filler, not a sin­gle pa­tient re­ceived the in­jec­tion within that cru­cial first hour and a half.

In the Auck­land case, which hap­pened in March, the der­mal filler had been in­jected by an ex­pe­ri­enced nurse, un­der the su­per­vi­sion of a plas­tic sur­geon. The woman who lost her sight de­clined to talk to North & South and her dev­as­tat­ing ex­pe­ri­ence has not pre­vi­ously been re­ported. But while it may have gone pub­licly un­no­ticed, what hap­pened that day has sent jit­ters through an in­dus­try des­per­ately want­ing to see reg­u­la­tory change.

Rosser’s not sur­prised by the case, the first of its kind in New Zealand. “Un­for­tu­nately, it’s one of those things that can’t nec­es­sar­ily be pre­vented,” he says. “It’s gen­er­ally bad luck when you enter a ves­sel that hap­pens to link with the oph­thalmic artery.”

What does sur­prise him is that so few com­pli­ca­tions are as­so­ci­ated with fa­cial filler. “The amaz­ing thing is that it’s as safe as it is, be­cause you’re in­ject­ing a for­eign body into some­one’s face, and yet it’s gen­er­ally fairly well tol­er­ated. The vast ma­jor­ity of peo­ple don’t end up with prob­lems.”

With the tow­er­ing, snow­dusted Re­mark­ables as their back­drop, the beau­ti­ful peo­ple have gath­ered in Queen­stown. Around 200 in­dus­try in­sid­ers, mainly doc­tors and nurses from around the coun­try, have poured into the tourist hotspot for the New Zealand So­ci­ety of Cos­metic Medicine’s an­nual sci­en­tific meet­ing – a three- day con­fer­ence with in­ter­na­tional speak­ers, mas­ter­classes and work­shops on ap­pear­ance medicine.

It’s hard not to gaze at their faces and won­der who’s had “work done”. Some are blessed with nat­u­ral (or sub­tly en­hanced) beauty; oth­ers ap­pear plumped to within an inch of burst­ing point, or flash flaw­less, frozen faces. Only a few seem com­fort­able ex­pos­ing the laugh­ter and frown lines we are all gifted in time.

There are two main treat­ments in the in­jectable world: Bo­tox, which is a pre­scrip­tion medicine and can only be in­jected by a trained pro­fes­sional or un­der the su­per­vi­sion of one; and der­mal filler, which is clas­si­fied in New Zealand as a med­i­cal de­vice and sub­ject to far less reg­u­la­tion, mean­ing it can es­sen­tially be in­jected by any­one.

Bo­tox is ac­tu­ally a brand name, but has be­come the go-to word for any sort of in­jectable de­rived from the toxin bo­tulinum but ad­min­is­tered in a highly di­luted dose. There are sev­eral other prod- ucts on the mar­ket, such as Dys­port, which ef­fec­tively do the same thing.

A tem­po­rary treat­ment that knocks out mus­cle ac­tion, it’s used to treat fine lines and wrin­kles by re­lax­ing fa­cial mus­cles, pre­vent­ing them from form­ing deeper lines. Re­sults aren’t im­me­di­ate and it usu­ally takes a few weeks for the full ef­fect. Bo­tox can treat crows’ feet, squint and frown lines, lines around the mouth and chin, fore­head creases, and lines in the neck area; it can also be used to help med­i­cal is­sues such as ex­ces­sive sweat­ing. Clients typ­i­cally spend around $300-$500 on a treat­ment, which will last be­tween three and five months.

Der­mal fillers, the other ma­jor area of in­jecta­bles, re­fill and re-in­flate ar­eas where you have fat loss, and stop skin sag­ging where you’ve lost vol­ume. Re­sults are im­me­di­ate but of­ten sub­tle.

“Peo­ple look a lot bet­ter but oth­ers can’t pin­point why,” says The Skin In­sti­tute’s Dr Hans Raetz, who is pres­i­dent of the New Zealand So­ci­ety of Cos­metic Medicine. “Clients don’t want to go to work the next day and have peo­ple say, ‘Oh, you had filler.’ They want to go to work and have peo­ple do a dou­ble-take, while try­ing to fig­ure out what’s dif­fer­ent.

“What our pa­tients like to hear is, ‘Oh, you had a great hol­i­day… you look so much fresher.’”

Filler also in­flates lips – a big trend in New Zealand right now. It’s where the term “trout pout” came from a few decades ago, but spe­cial­ists say it’s more about the nat­u­ral look now.

Col­la­gen, a nat­u­ral pro­tein which was all the rage as a skin plumper in the 90s, has been largely re­placed by hyaluronic acid fillers such as Juve­d­erm and Resty­lane, which don’t re­quire allergy tests, last longer and are more ver­sa­tile. (In­jectable col­la­gens are mostly made from pu­ri­fied cow and pig skin col­la­gen, while hu­man col­la­gen im­plants are more of­ten used to treat burns and ul­cers.)

In­dus­try ex­perts say 99 per cent of fillers used here now are based on hyaluronic acid, a sub­stance that oc­curs nat­u­rally in the body and is a com­mon in­gre­di­ent in anti- age­ing skin­care prod­ucts. More ex­pen­sive than Bo­tox, a filler treat­ment could cost be­tween $700 and $ 1500 and last any­where from six months to two years.

Over the past few years, the pop­u­lar­ity of in­jecta­bles has soared, not just with the old and wrinkly, but also with the

It took three-anda-half hours be­fore the woman was fi­nally in the right hands – those of Auck­land ocu­lo­plas­tic sur­geon and oph­thal­mol­o­gist Dr Paul Rosser. But in this case, it was too late.

young and beau­ti­ful. Treat­ments in­volve min­i­mal pain, very short re­cov­ery times, and are seen as a safer, less-in­va­sive, mod­ern al­ter­na­tive to a facelift or se­ri­ous plas­tic surgery. Star­tling re­sults are talked about openly in so­cial gath­er­ings and splashed over so­cial me­dia – some happy cus­tomers even live-stream di­rect from the treat­ment ta­ble. Like the wrin­kles th­ese der­mal fillers are used to treat, the stigma and se­crecy that once sur­rounded “ap­pear­ance medicine” seems to have sim­ply van­ished.

The con­fer­ence in Queen­stown starts with a min­gle and lunch. Ev­ery­one seems to know each other and there is much catch­ing up to be done as they foren­si­cally dis­sect their sand­wiches – leav­ing the bread and other carbs to one side, while in­hal­ing the pro­tein and veg­etable fill­ings. This is the ap­pear­ance in­dus­try and the ones cash­ing in on it are clearly health­con­scious. No sur­prise that they care about their looks.

The rock­ing tones of David Bowie’s “Let’s Dance” boom over the speak­ers – a sig­nal for ev­ery­one to move into the the­atre. It’s time to start.

Many of the doc­tors at­tend­ing are mem­bers of the so­ci­ety (NZSCM), the sin­gle uni­fied body for cos­metic medicine in this coun­try, which rep­re­sents doc­tors and pro­vides train­ing and su­per­vi­sion, as well as pro­fes­sional ac­cred­i­ta­tion.

The or­gan­i­sa­tion evolved four years ago from what be­gan with a small group of doc­tors who formed the Ap­pear­ance Medicine So­ci­ety of Aus­trala­sia (AMSA) in 1995. And while it’s still find­ing its feet, the so­ci­ety has around 60 mem­bers and hopes to ban­ish “cow­boys” from the busi­ness. It also runs New Zealand’s only Med­i­cal Coun­cil- ac­cred­ited pro­gramme to at­tain a prac­tis­ing Diploma in Cos­metic Medicine.

To­day, the first mas­ter­class is on anatomy. Aus­tralian plas­tic sur­geon Dr Peter Cal­lan doesn’t mince words when he talks about the risks of dan­ger zones on the face. The Auck­land blind­ness case is a hot topic, too. “Fillers [can be] dan­ger­ous,” he says. “I started in­ject­ing fillers in 1995, us­ing col­la­gen and we knew lit­tle about it then...”

Cal­lan flicks through a se­ries of slides that show a la­tex face be­ing in­jected and just what goes on un­der the skin as the in­jec­tor wiggles in a nee­dle or can­nula to plump out the wrin­kles and lines. “Do you know where you are?” he asks the au­di­ence. “It’s im­pos­si­ble to know where you are on the end of a nee­dle. Th­ese things are ev­ery­where – you’re al­ways in a blood ves­sel or com­ing out of one, so you just have to keep mov­ing.”

The crowd is cap­ti­vated by his en­ergy and charisma as he talks about com­pli­ca­tions from fillers. “You’re only re­mem­bered by your er­rors,” he says. “I give pa­tients my mo­bile num­ber and say, ‘Ring me at three in the morn­ing if you have pain or what­ever.’ If you’re go­ing to in­ject noses, you have to be pre­pared for trou­ble.”

The nose is one of two ar­eas on the face Cal­lan sig­nals as a red flag. The other is the glabella, just be­tween the eye­brows.

The dan­ger of blind­ness from in­jectable fillers hit the head­lines across the Tas­man in July, when top plas­tic sur­geons went

pub­lic to warn of this rare side- ef­fect. Plas­tic sur­geons talked of com­pla­cency in Aus­tralia, where be­ing in­jected with filler is as com­mon as hav­ing a man­i­cure or wax: the Aus­tralasian Col­lege of Cos­metic Surgery puts ex­pen­di­ture on cos­metic surgery and med­i­cal treat­ments at a bil­lion dol­lars a year. “With the in­crease in use has been an as­so­ci­ated down­grad­ing of the risks that come with hyaluronic acid fillers,” Aus­tralian So­ci­ety of Plas­tic Sur­geons (ASPS) pres­i­dent Mark Ash­ton told news.com.au.

The ar­ti­cle cited a new study from South Korea, which has the high­est num­ber of plas­tic and cos­metic pro­ce­dures per capita in the world. Nine pa­tients were ex­am­ined who had ex­pe­ri­enced vi­sion loss after be­ing in­jected with fillers. “All nine pa­tients were fe­male, rang­ing in age from 26 to 45, and in all cases hyaluronic acid fillers were in­jected by doc­tors, in­clud­ing board-cer­ti­fied plas­tic sur­geons and der­ma­tol­o­gists,” re­ported the study from Seoul Na­tional Uni­ver­sity, which was pub­lished in the jour­nal of the Amer­i­can So­ci­ety of Plas­tic Sur­geons.

Ash­ton warned that blind­ness from filler can oc­cur fol­low­ing an in­jec­tion any­where on the face, not only around the del­i­cate eye area – even with lip in­jec­tions, which are hugely pop­u­lar in Aus­tralia and New Zealand.

“The blind­ness is in­stan­ta­neous and per­ma­nent and can be one or both eyes. No one has been able to suc­cess­fully fix that blind­ness.”

Peter Cal­lan, based in Gee­long, Vic­to­ria, be­lieves open dis­cus­sion of the risks around fillers is the best thing that could have hap­pened here. At the Queen­stown con­fer­ence, he speaks with the blunt­ness of a man who’s dealt with the ugly side of the beauty in­dus­try, fix­ing filler side-ef­fects caused by his own and oth­ers’ mis­takes. “This tragic event [ in Auck­land] can only el­e­vate the stan­dards here,” he says. “I like that the New Zealand in­dus­try is dis­cussing it and try­ing to work out a way of pre­vent­ing it hap­pen­ing in the fu­ture. Th­ese events are very rare – but they do oc­cur.”

“If you’re go­ing to in­ject noses, you have to be pre­pared for trou­ble.” DR PETER CAL­LAN

So, why would any ap­pear­ance spe­cial­ist risk ma­jor med­i­cal mis­ad­ven­ture for the sake of mak­ing a few bucks out of giv­ing clients the line-free look?

Hans Raetz has been in­ject­ing faces with Bo­tox and fillers for decades, and the Auck­land case has him rat­tled. “I’m step­ping back from noses, now that we know what it can do,” he says. “I don’t have the ex­pe­ri­ence, so I send th­ese pa­tients off to some­one who does more noses. It’s a sta­tis­ti­cal cer­tainty that you will have a com­pli­ca­tion if you do enough of them.”

Raetz’s Ger­man ac­cent still lingers, blended with English and New Zealand tones. He’s well trav­elled, highly ed­u­cated and ex­pe­ri­enced, par­tially Bo­toxed him­self, and has been a prac­tis­ing doc­tor since grad­u­at­ing in 1991. He’s also a cham­pion for change.

In New Zealand, der­mal fillers (un­like Bo­tox) are clas­si­fied as med­i­cal de­vices. This means any­one can in­ject them – with no re­quire­ments for train­ing or qual­i­fi­ca­tions.

“Fillers are a free-for-all,” says Raetz. “Most drug com­pa­nies are some­what care­ful who they sup­ply to, but you can get fillers over the in­ter­net from Mex­ico, the US, Europe and China, no ques­tions asked. I’ve been of­fered Chi­nese fillers for $1 per millil­itre. There is ab­so­lutely no way this is a phar­ma­ceu­ti­cal prod­uct, ster­ile or even body- com­pat­i­ble. You might as well in­ject mo­tor oil.”

Fillers were re­clas­si­fied (from a medicine) by the Min­istry of Health and Med­safe in 2014, based on the fact that no bio­chem­i­cal change oc­curs in the body. How­ever Med­safe’s web­site warns of der­mal fillers’ as­so­ci­a­tion with blind­ness from cases dat­ing back to the late 80s; it ad­vises prac­ti­tion­ers to dis­cuss the risk with pa­tients, and warns fillers should not be used on cer­tain ar­eas of the face. It also states there is no pre-mar­ket ap­proval process for med­i­cal de­vices in New Zealand, so clin­i­cians who use filler should con­firm for them­selves that it’s been ap­proved by a reg­u­la­tory body for in­jec­tion, and that it’s safe.

Raetz claims the in­dus­try was blind­sided by Med­safe’s de­ci­sion to re­clas­sify filler, which he says was made with­out dis­cus­sion or con­sul­ta­tion, based on a lim­ited un­der­stand­ing of the im­pact fillers have. “If you put a hip re­place­ment in, that doesn’t cause any change in the body’s bio­chem­istry: there­fore it’s a med­i­cal de­vice, like a heart valve,” he says. “They [Med­safe] ap­plied the same rule for fillers. It just fills up and lifts the skin.

“We know now that’s rub­bish. Med­safe looked at this when the re­search on fillers was not fan­tas­tic and didn’t re­ally stress there was a bio­chem­i­cal change. We now know there cer­tainly is, be­cause once the filler has dis­ap­peared the skin has changed per­ma­nently – there’s a sig­nif­i­cant in­crease in the num­ber of col­la­gen fi­bres. It’s not just a bit of pad­ding you put in.”

Hyaluronidase (or Hyalase), the “fixit” drug that dis­solves the filler, is a pre­scrip­tion medicine and can only be in­jected by a doc­tor or un­der the su­per­vi­sion of one.

“If [a prod­uct] is a med­i­cal de­vice, Med­safe re­lies on the man­u­fac­turer ap­ply­ing an eth­i­cal sales pol­icy – which is fine for the big brands and sup­pli­ers. They don’t want to be as­so­ci­ated with stuff-ups, so they don’t sell to non-med­i­cal peo­ple,” says Raetz.

“But if you have a lit­tle Chi­nese out­fit in Bei­jing, for ex­am­ple, they don’t give a toss, re­ally. A beau­ti­cian here want­ing to in­ject fillers could go [to China], pack some into her suit­case and bring them

back. No one is go­ing to stop her. It’s not a medicine. Cus­toms don’t have any power, even if it is de­clared, which it prob­a­bly isn’t. It’s le­gal to bring it in and then it’s le­gal to in­ject it.”

Raetz wants to see filler re­clas­si­fied as a pre­scrip­tion-only medicine, which he be­lieves would pro­vide tighter guide­lines and con­trol over who can ad­min­is­ter it, and how. He’s been lob­by­ing Med­safe to re­visit the is­sue since the de­ci­sion to clas­sify filler as a med­i­cal de­vice was made in 2014.

Med­safe’s gen­eral man­ager, Chris James, ac­knowl­edges re­ceiv­ing a re­port about the woman left blind in one eye after be­ing in­jected with filler, de­scrib­ing it as a “rare but known pos­si­ble ad­verse event”. In the Ther­a­peu­tic Prod­ucts and Medicines Bill, ex­pected to go be­fore Par­lia­ment next year, Med­safe is look­ing at ex­tend­ing the clas­si­fi­ca­tion sys­tem cur­rently in place for medicines to other ther­a­peu­tic prod­ucts, and James says the Auck­land case helps demon­strate why in­clud­ing the use of med­i­cal de­vices needs to be ‘se­ri­ously con­sid­ered”.

A key con­cern for Raetz is that while doc­tors and reg­is­tered health pro­fes­sion­als (in­clud­ing nurses) can be held to ac­count by bod­ies such as the Med­i­cal Coun­cil and the NZ Health Prac­ti­tion­ers Dis­ci­plinary Tri­bunal, the cur­rent lack of reg­u­la­tion means oth­ers can in­ject filler with­out be­ing sub­ject to the same ethics and stan­dards. “The mo­ment you are not a doc­tor or nurse, the rules don’t ap­ply. The less qual­i­fied you are, the less that ap­plies. It’s in­sane.”

Blind­ness is not the only se­ri­ous risk or com­pli­ca­tion from fillers; you can lit­er­ally lose your face. The dan­ger comes once again by get­ting it into the wrong area – not just hit­ting a blood ves­sel or artery, but com­pletely fill­ing it up. If you cut off blood sup­ply to the face, the re­sult is sim­i­lar to frost­bite. “You lose the oxy­gen sup­ply to skin in that area, which means skin will die, ul­cer and even­tu­ally fall off,” says Raetz.

More mi­nor dam­age can be fixed by in­ject­ing Hyalase to dis­solve the filler within a 24-hour win­dow. It’s ex­pen­sive stuff, but Queen­stown- based Raetz keeps sev­eral vials of it at the ready – not just for emer­gen­cies but to dis­solve filler in the face that a client may not be happy with. “The main rea­son for me to have it in my clinic, and the rea­son I sleep at night, is I know if we in­ject some­thing we shouldn’t have, there’s a pretty good chance we can re­verse that be­fore it causes dam­age.”

Then, there’s the risk of dam­age by put­ting your face and your faith in the wrong hands. Raetz be­lieves a new dan­ger­ous and un­sta­ble black mar­ket is slowly emerg­ing on our shores.

“Peo­ple are go­ing into ho­tel rooms or pri­vate homes where they are in­ject­ing pa­tients. That’s in­sane. But let’s say the pa­tient is happy they’ll get an op­ti­mal out­come from that en­vi­ron­ment, then you need to be sure ev­ery­thing is on hand to deal with com­pli­ca­tions, be­cause some­times you only have min­utes to deal with them. You don’t want to have to drive for two or three hours to get some­thing done,” he says.

“It’s al­ready hap­pen­ing in Chi­nese com­mu­ni­ties; I’ve seen the videos, so it’s def­i­nitely hap­pen­ing. One of our col­leagues’ nurses is Chi­nese and ev­ery now and again she finds ads on Face­book and passes them on. But it’s dif­fi­cult to pin th­ese things down, be­cause it’s mostly on so­cial me­dia. There’s no ad­ver­tis­ing in the big pa­pers. You need to go look­ing for it and be able to trans­late Man­darin. We didn’t hear about this three or four years ago, and now I’m get­ting an email from mem­bers ev­ery few months ask­ing if we can do some­thing about this. The an­swer is no, we can’t.”

But the Health and Dis­abil­ity Com­mis­sioner can – to an ex­tent. While the HDC doesn’t mon­i­tor com­pli­ance, it will in­ves­ti­gate when a com­plaint is made.

Forty-two com­plaints about ap­pear­ance medicine have been in­ves­ti­gated by the HDC over the past decade, with the num­bers steadily in­creas­ing in more re­cent years. Most were over is­sues with treat­ment, con­sent or com­mu­ni­ca­tion.

ACC holds treat­ment in­jury data, but be­cause not all cases end up there, that’s not fully ac­cu­rate, ei­ther. It ac­cepted 98 claims in the past fi­nan­cial year re­lat­ing to ap­pear­ance medicine or cos­metic surgery, one of the high­est fig­ures in a decade. Most in­juries re­lated to breast re­con­struc­tion and im­plants, facelifts and nose jobs. But more com­mon pro­ce­dures such as laser treat­ment, fa­cial peels and col­la­gen in­jec­tions fea­tured sig­nif­i­cantly on the claim list, too. About 40 per cent of th­ese claims were for in­fec­tions.

Both Bo­tox and fillers are also read­ily avail­able in shop­ping malls, with some chemists of­fer­ing in­jectable treat­ments by a reg­is­tered nurse. The law doesn’t pre­vent this, but again Hans Raetz says pa­tients need to do their home­work about who is hold­ing the nee­dle, re­gard­less of where they choose to go.

So, apart from the odd rare com­pli­ca­tion, or per­haps be­ing left with a strange ex­pres­sion for a few months, where’s the hard ev­i­dence on the safety of in­jecta­bles? Put sim­ply, there isn’t any.

While Bo­tox is de­rived from the toxin which causes bot­u­lism – a rare but po­ten­tially fa­tal ill­ness – the dose used in cos­metic medicine is ex­tremely low and there have been no cases of poi­son­ing re­ported in New Zealand.

The owner of Auck­land’s Pon­sonby Cos­metic Med­i­cal Clinic, Dr Paul Nola, says, “We have Bo­tox data from the early 90s, and hyaluronic acid fillers from the late 90s, so we’re com­ing up to 30 years of data. We need to give it more time. But ba­si­cally, noth­ing has come up yet, which is as good as it’s go­ing to get.”

The main sup­pli­ers of in­jectable prod­ucts in New Zealand are Al­ler­gan, Gal­derma, Merz and NZMS (NZ Med­i­cal and Sci­en­tific), with a few other smaller play­ers that of­fer sin­gle prod­uct lines.

Raetz be­lieves lack of knowl­edge among the pub­lic and also within the ap­pear­ance medicine in­dus­try it­self is a key prob­lem. “There is still con­fu­sion even in our [med­i­cal] pop­u­la­tion over what qual­i­fi­ca­tion you need to in­ject th­ese prod­ucts,” he says.

In New Zealand, you can in­ject Bo­tox if you are a GP and have a Diploma in Cos­metic Medicine from the New Zealand So­ci­ety of Cos­metic Medicine; or if you’re a sur­geon or der­ma­tol­o­gist. It’s also le­gal for a nurse or a doc­tor who doesn’t hold the diploma to in­ject un­der su­per­vi­sion from a qual­i­fied doc­tor, sur­geon or der­ma­tol­o­gist. The prob­lem, says Raetz, is there are no guide­lines on what su­per­vi­sion means or how it is po­liced. He’d like to see the Med­i­cal Coun­cil lay down clearer rules.

“The Med­i­cal Coun­cil needs to clar­ify what ‘su­per­vi­sion’ ac­tu­ally is. Last time I was dis­cussing it with them, they said there were no rules about how many times a year you have to meet your sur­geon, or whether that sur­geon has to see the work you’ve done on pa­tients, or even if the sur­geon has to re­view your notes. There’s no au­dit­ing re­quired at all. So, at the mo­ment, if you meet your sur­geon once a year on the golf course, that could count as your su­per­vi­sion be­ing done.”

Raetz be­lieves that’s con­fus­ing and even dan­ger­ous. He wants the Med­i­cal Coun­cil to re­think its rules – es­pe­cially around filler. “If you don’t know what you’re do­ing, the like­li­hood of caus­ing last­ing dam­age is greatly in­creased. If you’re in­ject­ing fillers and you don’t have a li­cence, then you don’t have ac­cess to Hyalase, which is the only med­i­ca­tion that gets you out of the shit if you do have a side- ef­fect.”

When Raetz first learned about nasal in­jec­tions 10 or so years ago, he says us­ing filler wasn’t yet so­cially ac­cept­able and few pa­tients wanted it done. Now, he es­ti­mates the num­ber of filler pro­ce­dures has in­creased at least ten­fold.

In the Auck­land case, the der­mal filler was in­jected by a nurse un­der the su­per­vi­sion of a plas­tic sur­geon. What’s par­tic­u­larly wor­ry­ing, says Raetz, is that the nurse was highly spe­cialised

and ex­pe­ri­enced in nasal fillers – hav­ing per­formed, at her own es­ti­mate, some 800 in­jec­tions around the nose.

“She’s one of the more ex­pe­ri­enced in­jec­tors in that area. [But] if you do enough, even­tu­ally it will catch you. It’s a num­bers game. You get bet­ter [the more in­jec­tions you do], but you can’t com­pletely get out of that risk zone.”

Raetz says the nurse has now stopped per­form­ing that pro­ce­dure, but that presents its own prob­lems.

“So, who’s go­ing to do them? Pa­tients still want to get their nasal de­for­mi­ties sorted out. So they will go to some­one else who hasn’t heard about blind­ness or doesn’t re­ally give a toss. I’m not so sure that if you scare off the ex­pe­ri­enced op­er­a­tors, you’re go­ing to end up with a bet­ter out­come.”

The rip­ple ef­fect from the Auck­land pro­ce­dure go­ing so wrong has been far-reach­ing. In Hamil­ton, Dr Kir­shni Ap­panna spends half her time as a GP, the other half on cos­metic medicine. “Ev­ery time you have a nee­dle in your hand, you have the hee­bie-jee­bies,” she says. “It’s huge, huge talk in the in­dus­try right now and is so scary. I’ve al­ways been scep­ti­cal about do­ing fillers mid-face, in par­tic­u­lar, and after the nose-filler blind­ness case, I’ve put al­most ev­ery pa­tient off hav­ing nose filler done.”

Ap­panna is now very se­lec­tive about per­form­ing the pro­ce­dure and al­ways warns her pa­tients about the risk of blind­ness. Like Raetz, she wants to see filler re­clas­si­fied by Med­safe ur­gently and its use reg­u­lated. “It’s sick­en­ing what’s hap­pen­ing here in New Zealand – it def­i­nitely needs to change.”

Ap­panna is cute and quirky with a beam­ing smile and a nat­u­ral beauty. Her face lights up and moves as she talks; a blunt fringe bounces around un­der the rim of her hat. She loves car­ing for skin, she says. And if her own ap­pear­ance is any­thing to go by, she’s very good at it. But she is also far from blasé about the work she does. When it comes to Bo­tox and fillers, part of her con­sul­ta­tion process is spend­ing up to an hour on ed­u­cat­ing her pa­tients.

Ap­panna’s cos­metic clients are a mix of men and women in their 20s and 30s want­ing pre­ven­ta­tive work, as well as the rich, the fa­mous and more ma­ture clients. One woman saves up the money she earns from clean­ing to pay for her treat­ments. Younger clients aren’t wor­ried about lines and wrin­kles, she says; it’s all about plump­ing and im­pact. The trend is for big lips, big eye­brows and eye­lash ex­ten­sions and thick­en­ing. And it’s the younger women who tend to be loud and proud of their “work”.

“They’re so open about it and say, ‘I’m happy to put this up on Face­book; I’ll go on your In­sta­gram and be your am­bas­sador.’ It’s re­ally changed,” says Ap­panna, who had one client in her late 20s ask per­mis­sion to live-stream her lips be­ing in­jected and plumped. “It’s like they’re hav­ing their hair coloured. But they still have to re­mem­ber it’s a med­i­cal pro­ce­dure.”

She’s re­al­is­tic about what all th­ese prod­ucts and pro­ce­dures can re­ally achieve. Talk­ing to North & South dur­ing a break be­tween con­fer­ence ses­sions, she scans the room and low­ers her voice to a whis­per. “There are a few over­filled faces here... de­spite the risks. A lot of peo­ple have the over­filled look, but our the­ory is no one should know [you’ve had work done]. Ev­ery face tells a story. We can help you edit it, but we can’t help you change it.”

The stigma that once used to en­cour­age clients to keep their pro­ce­dures se­cret may have waned, but there are no of­fi­cial fig­ures on who is get­ting work done and mis­takes aren’t sub­ject to manda­tory re­port­ing, ei­ther.

The an­nual in­ter­na­tional IMCAS (In­ter­na­tional Mas­ter Course on Ag­ing Sci­ence) con­fer­ence, held in Lon­don last year, at­tracts around 8000 in­ter­na­tional del­e­gates from der­ma­tol­ogy, plas­tic surgery and re­lated pro­fes­sions to ex­plore the hottest top­ics in the med­i­cal aes­thetic field.

Fig­ures from 2016 put pa­tient spend on cos­metic medicine at $US12 bil­lion world­wide – a fig­ure climb­ing an­nu­ally by at least 10 per cent. It also re­ported that five per cent of all women in Europe use fa­cial in­jecta­bles, and the mar­ket size is pre­dicted to dou­ble by 2020.

Based on sup­plier in­for­ma­tion here, Raetz be­lieves the in­dus­try growth is sim­i­lar. “The year- on-year in­crease in cos­metic medicine ap­pears to be within that 10 per cent band, but to­tal growth is prob­a­bly up more like 15 per cent each year. We also have an in­crease in the num­ber of providers, clin­ics pop­ping up and new prod­uct lines com­ing on the mar­ket.”

Auck­land pay­roll man­ager Emma An­drews is the kind of client who’s boost­ing those sta­tis­tics. The 40-yearold mother of one could sim­ply have fab­u­lous genes – and she pos­si­bly does. But over the past 11 or so years, in­jecta­bles have be­come part of her beauty rou­tine. “I think pre­ven­tion is bet­ter than cure so you don’t have to try and get rid of wrin­kles, be­cause you don’t have them in the first in­stance.”

She be­lieves start­ing young means her an­nual spend of around $2500 is kept to a min­i­mum. “I have Bo­tox in my fore­head, crows’ feet and my frown lines be­tween my eyes. Most re­cently, I also started hav­ing it in my neck, which helps with ten­sion and grit­ting your teeth at night. I also have lip filler, be­cause my lips are un­even and a lit­tle bit of the ‘Kylie Jenner look’ is quite nice! Noth­ing too over the top, though.

“I’m not try­ing to get rid of ev­ery wrin­kle on my face – that would look silly. I think there’s a big fear you lose all ex­pres­sion and per­son­al­ity, and that’s not true, ei­ther. But you do feel a bit lighter, a bit hap­pier, a bit fresher. It has a psy­cho­log­i­cal ef­fect, but then so does ex­er­cise. It just makes you feel like you look that lit­tle bit younger – I don’t know why mak­ing your­self look younger makes you feel bet­ter, but it does.”

An­drews can’t name the risk fac­tors sur­round­ing her med­i­cal pro­ce­dures but is cer­tain she was told of them be­fore un­der­go­ing treat­ment. “I’m sure I read some­thing and signed it.” Told about the blind­ness case, she’s sur­prised. But while she says it sounds “hor­ren­dous”, it won’t put her off.

What she is very aware of, how­ever, is the dan­ger of hav­ing too much done, some­thing she of­ten sees in oth­ers. “The eye ad­justs re­ally quickly, so as

There’s big money in in­jecta­bles, with some self-em­ployed nurses mak­ing $5000 a day.

soon as you have a slightly fuller lip it be­comes the norm and you think, ‘Oh, I need to have a lit­tle bit more.’ You have to make sure you pull your­self back, and go, ‘Hang on, ac­tu­ally they look pretty darn good.’ Even peo­ple you see out in Auck­land – not just Hol­ly­wood stars – you think, ‘Jeez dude, slow down on it a bit.’”

Raetz says many of his clients at the Skin In­sti­tute in Queen­stown sim­ply “bud­get” their looks into their spend­ing. “They put money aside. You have some­one who makes 600 bucks a week, but some of that goes to­wards Bo­tox ev­ery three or four months. You get them from all walks of life.”

Raetz in­jects the rich and fa­mous, too, but says his client list is more var­ied now than ever. “I al­ways thought some­one who spent $400 on Bo­tox must have mas­sive dis­posal in­come. That’s not the case. You find some pa­tients rock up and pay a third with a cheque, and a third with a credit card, and an­other third they have in cash. They are the ones where hubby ob­vi­ously doesn’t know they’re hav­ing it done.” He laughs.

And Bo­tox and fillers are no longer just for women. Raetz says there’s a small, but grow­ing mar­ket for men. “I think it’s about ca­reer. Now you have to give the im­pres­sion of be­ing fresh and rested, even if you’re work­ing 12 hours a day.”

Back in Pon­sonby, Paul Nola has also seen a surge in clients want­ing a bit of “tox” and fillers in their lunch break. “When I started out, my clients wouldn’t tell any­one they came here, but now they do. Our big­gest source of new clients is re­fer­rals, which we never got back in the day, be­cause no one ever talked about it.”

He agrees it’s all about lips right now. “Lip fillers are the one: some­one has them and is straight on to In­sta­gram or Snapchat. There are a few peo­ple, even here [at the con­fer­ence] who’ve built an en­tire prac­tice on [lips].”

For the con­sumer, the cost of in­jectable pro­ce­dures doesn’t ap­pear to have dropped much since they hit the mar­ket in the 90s. There’s big money in the busi­ness, with some self- em­ployed nurses mak­ing $5000 a day.

“When I started the clinic 10 years ago, it was a good day if a pa­tient came through the door and spent $400 on Bo­tox,” says Raetz. “That was like… wow... she’s got lots of money, fan­tas­tic! Now, daily, my nurse will do five Bo­tox pa­tients, all for $350-$450 each, and pos­si­bly three fillers at $ 1500 each. That’s a lot of money.”

While Nola be­lieves while there is a moral re­spon­si­bil­ity to ad­vise young clients of the risks, he’s com­fort­able al­low­ing them to ex­plore what ap­pear­ance medicine has to of­fer.

“Some­times by giv­ing them a lit­tle bit of tox or filler, you im­prove their life mas­sively. But where is that line where you’re tak­ing ad­van­tage of th­ese peo­ple? You’re mak­ing money out of them, and there are ethics here. You still have to do the best for the pa­tient.”

Some of his clients are vul­ner­a­ble and suf­fer from body dys­mor­phic is­sues and se­vere anx­i­ety over their ap­pear­ance, he says, but for oth­ers it’s just the right medicine. “Yes, it’s a risky med­i­cal pro­ce­dure, but then the other ar­gu­ment is you’re only young once,” says Nola.

“I think if you don’t go too crazy, to have some lips done in your early 20s that are go­ing to dis­ap­pear in a year – is it re­ally such a big thing? They’re young and are go­ing to be old like the rest of us soon enough, so why not en­joy life?” +

Dr Paul Rosser

Del­e­gates from Queen­stown’s Skin In­sti­tute at the for­mal dinner and grad­u­a­tion cer­e­mony at the New Zealand So­ci­ety of Cos­metic Medicine’s an­nual con­fer­ence.

Dr Hans Raetz

Dr Paul Nola, owner of the Pon­sonby Cos­metic Med­i­cal Clinic in Auck­land. He says there’s not enough ev­i­dence yet to say in­jecta­bles are safe. “We need to give it more time. But ba­si­cally, noth­ing has come up yet, which is as good as it’s go­ing to get.”

Auck­land pay­roll man­ager Emma An­drews says in­jecta­bles have be­come part of her beauty rou­tine. “I think pre­ven­tion is bet­ter than cure so you don’t have to try and get rid of wrin­kles, be­cause you don’t have them in the first in­stance.”

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