From the newsrooms of the Sydney Morning Herald and The Age. This is the morning edition. I'm Samantha Salinger Morris. It's Tuesday, March 25th. Cosmetic injectables like Botox and dermal fillers have been around for so long now that it's easy to think that hopping into a chair to opt for a quick needle or two is about as routine as getting a haircut and is safe. But riding alongside the boom of this industry, now worth $4 billion in Australia, is easy access to telehealth appointments, which have led some people to getting injectables after a consultation with a doctor that lasts only 52 seconds. Today, senior reporter Henrietta Cooke and investigative reporter Clay Lucas on how often unintended and tragic consequences like permanent blindness can arise from these procedures and whether this is an industry that is slipping through the cracks in terms of adequate regulatory oversight.

From the newsrooms of the Sydney Morning Herald and The Age. This is the morning edition. I'm Samantha Salinger Morris. It's Tuesday, March 25th. Cosmetic injectables like Botox and dermal fillers have been around for so long now that it's easy to think that hopping into a chair to opt for a quick needle or two is about as routine as getting a haircut and is safe. But riding alongside the boom of this industry, now worth $4 billion in Australia, is easy access to telehealth appointments, which have led some people to getting injectables after a consultation with a doctor that lasts only 52 seconds. Today, senior reporter Henrietta Cooke and investigative reporter Clay Lucas on how often unintended and tragic consequences like permanent blindness can arise from these procedures and whether this is an industry that is slipping through the cracks in terms of adequate regulatory oversight.

So, Clay and.

So, Clay and.

Henrietta, before we get into your investigation, can you just give us a rundown about what cosmetic injectables actually are? Henrietta, I'll go to you first.

Henrietta, before we get into your investigation, can you just give us a rundown about what cosmetic injectables actually are? Henrietta, I'll go to you first.

Yeah. One of the most common ones is known by the name of Botox. It's a type of botulinum that blocks nerve signals to muscles, which temporarily prevents them from contracting. Um, it's used for cosmetic and medical purposes. So it stops the muscles in the face from moving, reducing the appearance of wrinkles. The other popular substance is dermal filler. That's a gel like substance that is injected under the skin to smooth wrinkles, plump skin, and improve facial contours. Um, these are both substances that are used to prevent signs of aging and improve the appearance of the skin.

Yeah. One of the most common ones is known by the name of Botox. It's a type of botulinum that blocks nerve signals to muscles, which temporarily prevents them from contracting. Um, it's used for cosmetic and medical purposes. So it stops the muscles in the face from moving, reducing the appearance of wrinkles. The other popular substance is dermal filler. That's a gel like substance that is injected under the skin to smooth wrinkles, plump skin, and improve facial contours. Um, these are both substances that are used to prevent signs of aging and improve the appearance of the skin.

And so how much do procedures like this actually cost?

And so how much do procedures like this actually cost?

They can vary in price, but we've found for basic Botox starting at $300 is is usually the starting point. Um, lip filler tends to be a bit more expensive, sort of $600 650 for one mil, which is a reasonable amount for lip plumping. And then you get procedures right up to a couple of thousand for what they call a non-surgical Brazilian butt lift. A US firm did an analysis of our market in 2023, and they found that it was worth around Australian $4 billion a year, and they predicted that over the next five years, it'll grow to be worth $9 billion by the year 2030. So it's really growing fast. You can see it everywhere in every shopping centre in Australia now has, uh, I guess a day spa or a beauty clinic or a hairdresser that also offers, um, cosmetic injectables of one form or another. So you can really find injectables on every street corner in Australia.

They can vary in price, but we've found for basic Botox starting at $300 is is usually the starting point. Um, lip filler tends to be a bit more expensive, sort of $600 650 for one mil, which is a reasonable amount for lip plumping. And then you get procedures right up to a couple of thousand for what they call a non-surgical Brazilian butt lift. A US firm did an analysis of our market in 2023, and they found that it was worth around Australian $4 billion a year, and they predicted that over the next five years, it'll grow to be worth $9 billion by the year 2030. So it's really growing fast. You can see it everywhere in every shopping centre in Australia now has, uh, I guess a day spa or a beauty clinic or a hairdresser that also offers, um, cosmetic injectables of one form or another. So you can really find injectables on every street corner in Australia.

And so why? Why is this growing so much in popularity?

And so why? Why is this growing so much in popularity?

I think there's intense pressure on people to look youthful. Social media is driving this, and these procedures people use to sort of seek them out, perhaps when they were in their 40s. 50s 60s. Now you're seeing young women in their 20s and 30s getting Botox and filler treatments.

I think there's intense pressure on people to look youthful. Social media is driving this, and these procedures people use to sort of seek them out, perhaps when they were in their 40s. 50s 60s. Now you're seeing young women in their 20s and 30s getting Botox and filler treatments.

Kylie Jenner, everybody knows who she is. And they say she really is responsible for the recent trends in cosmetic surgery, cosmetic medicines and fillers.

Kylie Jenner, everybody knows who she is. And they say she really is responsible for the recent trends in cosmetic surgery, cosmetic medicines and fillers.

All right, mum, where are we? You're getting Botox. We're getting birthday Botox. I like my nose. I just feel like when I smile, it goes really far down. So I like when it's just got that slight little lift there.

All right, mum, where are we? You're getting Botox. We're getting birthday Botox. I like my nose. I just feel like when I smile, it goes really far down. So I like when it's just got that slight little lift there.

Filler is going to be out. It's going to be bio stimulators that are in which are injectable substances.

Filler is going to be out. It's going to be bio stimulators that are in which are injectable substances.

This culture of fillers and Botox and plastic surgery, all of these things that were reserved for the Hollywood elite.

This culture of fillers and Botox and plastic surgery, all of these things that were reserved for the Hollywood elite.

I think this used to be the domain of the super rich, and now it's become something that just everyone can afford. And it's seen as a way of sort of pampering yourself.

I think this used to be the domain of the super rich, and now it's become something that just everyone can afford. And it's seen as a way of sort of pampering yourself.

As a result of this, people have lost sight of the fact that these are actually medical procedures, not just cosmetic procedures, not something as simple as getting a haircut or your nails done.

As a result of this, people have lost sight of the fact that these are actually medical procedures, not just cosmetic procedures, not something as simple as getting a haircut or your nails done.

Okay. And Henrietta, so what is the process that someone actually goes through in order to get Botox or another similar procedure?

Okay. And Henrietta, so what is the process that someone actually goes through in order to get Botox or another similar procedure?

Well, if you're using a telehealth doctor, what you would do is you'd go to one of these beauty clinics, and a nurse injected there would probably run you through a few of the side effects. Um, she will then, or he will phone a telehealth company and a doctor will remotely write a script for, um, whatever the substance is that you're injecting in your face. So Botox or dermal fillers. So the doctor will often appear on a screen.

Well, if you're using a telehealth doctor, what you would do is you'd go to one of these beauty clinics, and a nurse injected there would probably run you through a few of the side effects. Um, she will then, or he will phone a telehealth company and a doctor will remotely write a script for, um, whatever the substance is that you're injecting in your face. So Botox or dermal fillers. So the doctor will often appear on a screen.

Hi, I'm John, I'm the doctor.

Hi, I'm John, I'm the doctor.

On the nurses phone and have a very brief conversation with the patient.

On the nurses phone and have a very brief conversation with the patient.

We just have to have a quick chat as part of the regulations. Do you have any questions at all for me?

We just have to have a quick chat as part of the regulations. Do you have any questions at all for me?

They will peer through the phone and look at the patient.

They will peer through the phone and look at the patient.

I can go over the medical record here and see that you're appropriate for treatment. So we'll just go over the risks one more time.

I can go over the medical record here and see that you're appropriate for treatment. So we'll just go over the risks one more time.

And run through a list of all the potential side effects associated with the treatment.

And run through a list of all the potential side effects associated with the treatment.

Bleeding, bruising, infection or swelling can occur with any injection. There's a small chance that the anti-wrinkle can cause a droop of the muscle. It's about a 1% risk. It always goes away if it happens. Are you happy to go ahead? Yep.

Bleeding, bruising, infection or swelling can occur with any injection. There's a small chance that the anti-wrinkle can cause a droop of the muscle. It's about a 1% risk. It always goes away if it happens. Are you happy to go ahead? Yep.

The concern is that a lot of these consultations are taking place in an incredibly short period of time. We found evidence of some of these consultations running for just 52 seconds.

The concern is that a lot of these consultations are taking place in an incredibly short period of time. We found evidence of some of these consultations running for just 52 seconds.

All right. Wonderful wish. All the best. Thanks so much. Thanks. Bye.

All right. Wonderful wish. All the best. Thanks so much. Thanks. Bye.

And so, Clay, how widespread, I guess is telehealth when it comes to these appointments and how common is it I guess for one of those consultations with the doctors to be 52 seconds.

And so, Clay, how widespread, I guess is telehealth when it comes to these appointments and how common is it I guess for one of those consultations with the doctors to be 52 seconds.

So this all started when we were sent in October last year, a job ad for a company called Angel aesthetics on the Gold Coast, and they were seeking a telehealth doctor to do 150 to 200 calls a week. And it stated, just bluntly stated, most consults will be 1 to 2 minutes long, and then you'll have to spend five seconds filling out a script. And when we got that, we thought, well, this seems like an issue. But when we looked further, we found that Australia's biggest telehealth clinic was a company called Fresh Clinics. Now they provide services to between 1500 and 2000 nurses in clinics all over Australia. And they're the biggest. But there's a few others. One's called duvet. One's called triple A, another is called APA. According to Fresh's own research, they do. 80% of the appointments in this industry is done by telehealth, so it's a huge industry. The companies make money by charging $25 per consult to the nurse. This is fresh. Fresh charges $25 per consult, but they also make a lot of money by then selling the product to those nurses.

So this all started when we were sent in October last year, a job ad for a company called Angel aesthetics on the Gold Coast, and they were seeking a telehealth doctor to do 150 to 200 calls a week. And it stated, just bluntly stated, most consults will be 1 to 2 minutes long, and then you'll have to spend five seconds filling out a script. And when we got that, we thought, well, this seems like an issue. But when we looked further, we found that Australia's biggest telehealth clinic was a company called Fresh Clinics. Now they provide services to between 1500 and 2000 nurses in clinics all over Australia. And they're the biggest. But there's a few others. One's called duvet. One's called triple A, another is called APA. According to Fresh's own research, they do. 80% of the appointments in this industry is done by telehealth, so it's a huge industry. The companies make money by charging $25 per consult to the nurse. This is fresh. Fresh charges $25 per consult, but they also make a lot of money by then selling the product to those nurses.

Okay, but online appointments, I mean, they are pretty par for the course now, right? In medicine ever since the Covid 19 pandemic. So Henrietta, I'm just going to go to you. What other problems are we seeing here with regards to telehealth appointments in this industry?

Okay, but online appointments, I mean, they are pretty par for the course now, right? In medicine ever since the Covid 19 pandemic. So Henrietta, I'm just going to go to you. What other problems are we seeing here with regards to telehealth appointments in this industry?

I guess in this space there is a a treatment that takes place after the telehealth appointment. It's not simply a check in with a doctor that you might do if you're sick or need a prescription for something, there's actually a medical procedure that takes place. So it's quite unlike other forms of telehealth. Um, also, I guess you've got a situation where the nurse and the doctor are not working side by side. So the issue is that there's not that sort of oversight that you would get in a sort of traditional clinic setting with a doctor who is prescribing, um, a sort of cosmetic procedures. And I guess also the issue is if something does go wrong, you don't have a doctor immediately available. Sometimes there interstate. We've also come across cases where they're overseas. So the management of that complication is, um, you know, that presents challenges.

I guess in this space there is a a treatment that takes place after the telehealth appointment. It's not simply a check in with a doctor that you might do if you're sick or need a prescription for something, there's actually a medical procedure that takes place. So it's quite unlike other forms of telehealth. Um, also, I guess you've got a situation where the nurse and the doctor are not working side by side. So the issue is that there's not that sort of oversight that you would get in a sort of traditional clinic setting with a doctor who is prescribing, um, a sort of cosmetic procedures. And I guess also the issue is if something does go wrong, you don't have a doctor immediately available. Sometimes there interstate. We've also come across cases where they're overseas. So the management of that complication is, um, you know, that presents challenges.

And what are the doctors who are actually running these online appointments, say, like what are the benefits?

And what are the doctors who are actually running these online appointments, say, like what are the benefits?

So Fresh Clinics has defended themselves by telling us that the nurses in these appointments will do quite an extensive pre check of the patient before they then come and meet the doctor for what is an average, we're told, in fresh clinics of around 30s. They haven't confirmed that for us. But that's what we've been told over and over and over by everyone in the industry. A couple of weeks ago at a cosmetic conference, there was a cosmetic doctor who got up and said there was some doctors in this telehealth space doing 300 telehealth prescriptions per day in cosmetic injectables, which is an incredible amount.

So Fresh Clinics has defended themselves by telling us that the nurses in these appointments will do quite an extensive pre check of the patient before they then come and meet the doctor for what is an average, we're told, in fresh clinics of around 30s. They haven't confirmed that for us. But that's what we've been told over and over and over by everyone in the industry. A couple of weeks ago at a cosmetic conference, there was a cosmetic doctor who got up and said there was some doctors in this telehealth space doing 300 telehealth prescriptions per day in cosmetic injectables, which is an incredible amount.

You know, I am aware, and I can say this for a fact, that I know that some of the telehealth doctors have done up to 300 consultations in a single day with video consultations. Now, that's completely ridiculous. And I would suggest.

You know, I am aware, and I can say this for a fact, that I know that some of the telehealth doctors have done up to 300 consultations in a single day with video consultations. Now, that's completely ridiculous. And I would suggest.

But they defend themselves by saying the nurses generally have impeccable safety records. They do a lot of screening before their patient meets the doctor, and then they say that they have this 24 over seven system in place where if something goes wrong, the patient can always get in touch with that and get a doctor. We've got evidence that that doesn't always work, but, you know, that's how they defend themselves.

But they defend themselves by saying the nurses generally have impeccable safety records. They do a lot of screening before their patient meets the doctor, and then they say that they have this 24 over seven system in place where if something goes wrong, the patient can always get in touch with that and get a doctor. We've got evidence that that doesn't always work, but, you know, that's how they defend themselves.

We'll be right back. And Henrietta. I believe one of the sort of risk factors in this particular space with regards to telehealth is that, you know, there won't be appropriate screening, I guess, of patients who perhaps are suffering from disorders like body dysmorphia. Is that right?

We'll be right back. And Henrietta. I believe one of the sort of risk factors in this particular space with regards to telehealth is that, you know, there won't be appropriate screening, I guess, of patients who perhaps are suffering from disorders like body dysmorphia. Is that right?

Yeah, that's an issue that quite a few psychologists raised with us. Under Australian rules, there is meant to be an assessment of each patient, and that is meant to look at whether or not they suffer from body dysmorphic disorder, which is estimated to be something that about 20% of people who are seeking surgical and non-surgical procedures suffer from. I think people who suffer from body dysmorphic disorder, um, they have unrealistic beauty standards. Um, I guess when you are someone who experiences that, you're also very vulnerable to upselling. So, um, we have interviewed some patients who have gone in to see a nurse or a doctor for a certain issue that they would like to fix, and been told that they might benefit from other work on their face and have felt quite vulnerable and yet slightly exploited. So they've gone on to have work that they didn't initially intend to have, and also become quite fixated on this issue that they didn't previously think they had. So there's concerns that that sort of screening isn't taking place in a particularly thorough way.

Yeah, that's an issue that quite a few psychologists raised with us. Under Australian rules, there is meant to be an assessment of each patient, and that is meant to look at whether or not they suffer from body dysmorphic disorder, which is estimated to be something that about 20% of people who are seeking surgical and non-surgical procedures suffer from. I think people who suffer from body dysmorphic disorder, um, they have unrealistic beauty standards. Um, I guess when you are someone who experiences that, you're also very vulnerable to upselling. So, um, we have interviewed some patients who have gone in to see a nurse or a doctor for a certain issue that they would like to fix, and been told that they might benefit from other work on their face and have felt quite vulnerable and yet slightly exploited. So they've gone on to have work that they didn't initially intend to have, and also become quite fixated on this issue that they didn't previously think they had. So there's concerns that that sort of screening isn't taking place in a particularly thorough way.

Okay. And Clay, what other risks, I guess, are associated with some of these procedures that are taking place that you've written about?

Okay. And Clay, what other risks, I guess, are associated with some of these procedures that are taking place that you've written about?

The most common thing that can go wrong is a thing called a vascular occlusion, which is particularly risky in the use of dermal fillers. So if you're having, um, lip plumping done or filler injected into your cheeks or into your, you know, into your, your eye tear trough, what can happen is that filler which can be quite solid, can get into your artery and then block the blood supply, and that can eventually kill the skin in that area if you don't get onto it straight away. One of the issues that seems to come up a lot is that if your doctor is only available via telehealth, it can be a struggle to get to that doctor to ask them what to do. And as often as not, they'll just tell you to go to emergency. We interviewed a doctor for this series of stories who works in emergency, who said he was seeing more and more people coming in with a vascular occlusion with, with, you know, with the the blood supply to the skin blocked. And that can lead to really terrible consequences. It's not common. But when it does happen, it's terrible. The worst consequences of that as well can be blindness. And we got figures from the Therapeutic Goods Administration which found that in the last few years, eight people have been blinded by cosmetic injectables and 81 people have had really serious eye disorders as a result of getting injections.

The most common thing that can go wrong is a thing called a vascular occlusion, which is particularly risky in the use of dermal fillers. So if you're having, um, lip plumping done or filler injected into your cheeks or into your, you know, into your, your eye tear trough, what can happen is that filler which can be quite solid, can get into your artery and then block the blood supply, and that can eventually kill the skin in that area if you don't get onto it straight away. One of the issues that seems to come up a lot is that if your doctor is only available via telehealth, it can be a struggle to get to that doctor to ask them what to do. And as often as not, they'll just tell you to go to emergency. We interviewed a doctor for this series of stories who works in emergency, who said he was seeing more and more people coming in with a vascular occlusion with, with, you know, with the the blood supply to the skin blocked. And that can lead to really terrible consequences. It's not common. But when it does happen, it's terrible. The worst consequences of that as well can be blindness. And we got figures from the Therapeutic Goods Administration which found that in the last few years, eight people have been blinded by cosmetic injectables and 81 people have had really serious eye disorders as a result of getting injections.

I mean, it's pretty shocking. Henrietta, I just want to go to you now. More broadly, I guess what's happening with the oversight of this industry. Like, is there a gap here?

I mean, it's pretty shocking. Henrietta, I just want to go to you now. More broadly, I guess what's happening with the oversight of this industry. Like, is there a gap here?

Each state has slightly different rules and regulations around this. In December, Queensland Health issued a fact sheet, and it basically stated that only doctors and nurse practitioners can purchase Botox and cosmetic fillers. If that was in force, that would sort of throw the whole industry of nurse led clinics into disarray. Um, New South Wales has similar rules. Um, but whether or not they're enforced, I think is another matter. There's been a bit of a pushback to the clarification of these rules. Petition has been started that criticises those rules and said that it's going to throw the sector into disarray.

Each state has slightly different rules and regulations around this. In December, Queensland Health issued a fact sheet, and it basically stated that only doctors and nurse practitioners can purchase Botox and cosmetic fillers. If that was in force, that would sort of throw the whole industry of nurse led clinics into disarray. Um, New South Wales has similar rules. Um, but whether or not they're enforced, I think is another matter. There's been a bit of a pushback to the clarification of these rules. Petition has been started that criticises those rules and said that it's going to throw the sector into disarray.

And one of the ideas has actually been to establish a mandatory register of complications. So tell us about that.

And one of the ideas has actually been to establish a mandatory register of complications. So tell us about that.

Yeah. So we don't actually have a sense of how many complications are occurring. People and hospitals can report complications to the Therapeutic Goods Administration. But yeah, we don't actually have a sense of how often things like vascular occlusions and other complications are occurring. So some people who want to clean up the sector are calling for some transparency in terms of, um, you know, how many complications are arising because we just don't know. And there's often a great deal of, I think, shame and stigma when things go wrong, particularly when patients have sought out these treatments to fix parts of their body that they don't like and then are left with a worse situation.

Yeah. So we don't actually have a sense of how many complications are occurring. People and hospitals can report complications to the Therapeutic Goods Administration. But yeah, we don't actually have a sense of how often things like vascular occlusions and other complications are occurring. So some people who want to clean up the sector are calling for some transparency in terms of, um, you know, how many complications are arising because we just don't know. And there's often a great deal of, I think, shame and stigma when things go wrong, particularly when patients have sought out these treatments to fix parts of their body that they don't like and then are left with a worse situation.

And so, Clay, just to wrap up, what happens from here. I mean, does there need to be further intervention to protect patients?

And so, Clay, just to wrap up, what happens from here. I mean, does there need to be further intervention to protect patients?

Yeah, the entire industry is waiting on new guidelines that are going to be issued soon by one of the federal health regulators. That will clarify a lot of the rules around this area, but it does feel a little bit like this, along with all of the sorts of medicines that are being scripted via telehealth that aren't part of Medicare. It does feel this sort of Wild West feeling of everyone's just doing what they can get away with. The regulators find it really hard to crack down on them. There's very little prosecution done by federal authorities of people who breach advertising guidelines, for instance. So unless the rules change pretty quickly and pretty rapidly, then it seems like it's just going to get worse rather than better in this space.

Yeah, the entire industry is waiting on new guidelines that are going to be issued soon by one of the federal health regulators. That will clarify a lot of the rules around this area, but it does feel a little bit like this, along with all of the sorts of medicines that are being scripted via telehealth that aren't part of Medicare. It does feel this sort of Wild West feeling of everyone's just doing what they can get away with. The regulators find it really hard to crack down on them. There's very little prosecution done by federal authorities of people who breach advertising guidelines, for instance. So unless the rules change pretty quickly and pretty rapidly, then it seems like it's just going to get worse rather than better in this space.

We're so lucky that you're investigating this area. So thank you so much, Henrietta and Clay, for your time.

We're so lucky that you're investigating this area. So thank you so much, Henrietta and Clay, for your time.

Thank you very much.

Thank you very much.

Thanks for having us on.

Thanks for having us on.

Today's episode of The Morning Edition was produced by Tammy Mills, with technical assistance by Josh towers. Tom McKendrick is our head of audio. The Morning Edition is a production of The Age and The Sydney Morning Herald. To support our journalism, subscribe to us by visiting The Age or smh.com.au. Forward slash, subscribe and sign up for our Morning Edition newsletter to receive a comprehensive summary of the day's most important news, analysis and insights in your inbox every day. Links are in the show. Notes. I'm Samantha Selinger. Morris. This is the morning edition. Thanks for listening.

Today's episode of The Morning Edition was produced by Tammy Mills, with technical assistance by Josh towers. Tom McKendrick is our head of audio. The Morning Edition is a production of The Age and The Sydney Morning Herald. To support our journalism, subscribe to us by visiting The Age or smh.com.au. Forward slash, subscribe and sign up for our Morning Edition newsletter to receive a comprehensive summary of the day's most important news, analysis and insights in your inbox every day. Links are in the show. Notes. I'm Samantha Selinger. Morris. This is the morning edition. Thanks for listening.