By Adele Ferguson
Ella Callis was left in extreme pain after cosmetic surgery went wrong. Credit:Simon Schluter
Ella Callis records it all. The bed she wakes up in, the sheets sodden with blood and fluids, how she becomes conscious mid-surgery and feels a long cannula being thrust in and out of her stomach. “It is scary,” she sobs into her phone camera.
Callis was having a Brazilian Butt Lift (BBL) and liposuction in five places, including her chin and abdomen, at a Cosmos Clinic in Melbourne on April 13, 2021. “I could feel them with the cannula ramming me.”
The cosmetic surgeon was Dr Reza Ahmadi, who 16 days later would perform a BBL on Keisha Amoah and accidentally liposuck her liver more than 17 times, leaving her in pain and with enduring nerve damage.
Ahmadi was contacted by this masthead but said his lawyers advised him not to comment.
For Callis the videos and photos became a diary of her cosmetic surgery ordeal. “I’m glad I have proof of how filthy and disgusting the bed was that I woke up in,” she says.
Within days of the procedure, she developed a foul-smelling infection in her groin. “It was like a dead animal … the same smell as when you walk past a dead animal.”
It then spread to her genitals, blowing her vulva to the size of an orange. Getting little help from the clinic, she took herself to the Alfred Hospital in Melbourne, where she stayed for three days on intravenous antibiotics.
In the latest investigation by The Sydney Morning Herald, The Age and 60 Minutes into the $1.4 billion cosmetic surgery industry, it can be revealed that in 2021 at least eight patients of Ahmadi ended up in hospital with serious infections.
Over the past 10 months, this masthead has received hundreds of emails and calls from patients of cosmetic surgeons who are living with disfigurement and pain.
This masthead’s June investigation was delayed by three weeks as founder Dr Joseph Ajaka rushed to court after receiving a series of questions ahead of publication. While the story was held up, two patients ended up in hospital in Sydney after serious infections post-surgery.
Dr Reza Ahmadi, who was a cosmetic surgeon at Cosmos, in a social media post.
After the Court of Appeal threw out Ajaka’s claim and the story appeared, Cosmos threatened to sue for defamation but did not go through with the threat.
At the time of the June story Cosmos said in a statement that “patient safety informs everything that we do”.
In February this year Cosmos terminated Ahmadi’s employment.
“We are legally prevented from commenting on the circumstances surrounding the termination of the employment of Dr Ahmadi and his team as well as our role in having conditions placed on Dr Ahmadi’s registration,” Cosmos Clinic said in June in a press release. “We are sorry that this occurred and want to assure the public that we investigated and acted as soon as we became aware of the allegations against him.”
These are just a fraction of the failings in a poorly regulated sector that allows doctors with basic medical degrees who have completed weekend courses to call themselves cosmetic surgeons.
Oversight is so lax that many experts are calling for a complete rethink of the regulatory structure and a royal commission to expose the extent of the failings in an industry out of control.
An exposé into Daniel Lanzer’s network of clinics last October revealed a litany of safety and hygiene issues – then this masthead’s June investigation into Cosmos Clinics exposed questionable conduct at the country’s biggest cosmetic procedure network.
Raid revelations
Today, the casualties continue. Patients’ injuries come from big and small operators, who have been able to exploit gaping holes in the regulatory system to create a new kind of doctor-cum-entrepreneur, driven by profits and brand, not patients’ interests.
A list of up to 80 patients from Cosmos in Melbourne was presented to the Victorian Department of Health in March to investigate whether their 2021 surgeries were in breach of a public health order that banned cosmetic surgery during lockdown.
While the department took more than three months to raid Cosmos Melbourne after that complaint, it was much quicker to raid the workplace of esteemed plastic surgeon professor Mark Ashton’s Epworth Freemasons practice shortly after getting an anonymous tip following a promotion for a 60 Minutes exposé on the industry.
“The raid on my rooms shows that anyone who tries to take this industry on, be ready, they’re going to come after you. And they’ve come after me, they’ve come after you [the author], they come after us all because we’re shining a light onto a part of the industry they just don’t want to show,” he says.
Surgeon Mark Ashton, whose offices were raided following an anonymous tip after he spoke out about cosmetic surgery abuses.Credit:Nine/60 Minutes
This raid has raised a broader issue about the priorities of the regulators, and how effectively they are fulfilling their key role to keep patients safe.
The Australian Health Practitioner Regulation Agency (AHPRA) prides itself on being a risk-based regulator with a guiding principle of “minimum compliance and enforcement action appropriate to manage the risk posed, to protect the public”.
Social media experts Maddison Johnstone and Michael Fraser say this is basically saying the agency will do only the minimum. “This policy means doctors are being given the green light to advertise how they want as the benefits to their business outweigh the risks,” Johnstone says.
Many experts believe patients aren’t adequately protected. They argue it isn’t just cosmetic cowboys at fault but regulators that allow them to operate with virtual immunity.
Regulatory specialist Andy Schmulow describes AHPRA as a “broken and dysfunctional regulator, weak, feckless, suborned”.
“Once you have failed to adhere to your principles of priority, number one, patient welfare, I think that’s a fatal error,” he says.
Lawyer Margaret Faux, who is also a registered nurse and health regulation expert of 40 years, says the health system is an incoherent mess and describes AHPRA as pathetic.
“It’s not a question of them being asleep at the wheel, they’re nowhere near the car. They’re just nowhere,” she says.
Professor Allan Fels, the former head of the Australian Competition and Consumer Commission, a former hospital director and former chairman of the National Mental Health Commission, is also concerned.
“AHPRA is ineffective in protecting the public from very dangerous practices in cosmetic surgery … that’s not good enough for a regulator where public health is at risk,” he says.
One of AHPRA’s responsibilities is policing social media to ensure doctors don’t breach advertising rules or cross the line when it comes to marketing.
The agency’s chief executive, Martin Fletcher, fronted the Queensland parliament in June arguing in favour of lifting a ban on doctors using patient testimonials in advertising.
Cosmetic cowboys operate with little oversight
- Cosmetic surgery industry is worth $1.4b a year in Australia
- An estimated 500,000 cosmetic surgery procedures a year. There is a lack of official data.
- If you include laser surgery, injectables and non surgical fat reduction, Australians spend more than $6 billion a year
- Hundreds, and possibly thousands, of patients have been maimed, scarred and permanently damaged by botched surgeries. Again, there is no official data.
- 540 patients have joined a class action against Daniel Lanzer cosmetic surgery clinics
- 65 patients have contacted lawyers regarding a class action against Cosmos Clinics
- There is a confusing maze of regulators, state and federal
- Different states have different rules about what is safe
“Truth and honesty are at the heart of the relationship between a patient and their health practitioner,” Fletcher told parliament. “The proposed legislation will help uphold this core value.”
Johnstone and Fraser, who have been effectively doing AHPRA’s job over the past two years in policing more than 100 cosmetic surgeons’ social media posts, are devastated by the move.
Social media experts Maddison Johnstone and Michael Fraser have been investigating social media use in the cosmetic surgery industry.Credit:Paul Harris
“It’s already a billion-dollar industry, and I think that’s largely due to social media,” Johnstone says. “So by plugging testimonials, my fear is that it will really double the problems we’re seeing.”
Fraser points to the many cosmetic doctors already pushing the boundaries, citing one post by Cosmos of a man bleeding from his chest but saying he was happy with his surgery. There are also videos in which a surgeon shows a patient the results of their surgery while they are still on the operating table, possibly medicated and emotional, and they laugh or cry.
“It’s not a question of [AHPRA] being asleep at the wheel, they’re nowhere near the car.”
The peak body for doctors, the Australian Medical Association, described AHPRA’s social media decision as bizarre. Former AMA president Dr Omar Khorshid said there were good reasons the current ban exists.
“It protects patients, in particular vulnerable patients, from false and misleading advertising,” Dr Khorshid says.
The Herald, The Age and 60 Minutes investigation has trawled thousands of leaked WhatsApp messages between doctors and nurses at the Daniel Lanzer network of cosmetic clinics, as well as social media accounts, many of which were deleted, and found more damning behaviour.
Social media sensation Dr Daniel Aronov performs surgeries in an unregistered facility in Sydney. Doctors including Aronov and Lanzer do major surgeries in registered day hospitals but use non-dedicated operating theatres such as side rooms and offices.
In a message to a nurse, Aronov says, “I told a patient to come at 6.15. I’m going to mark then leave for haircut 6.45 while you fill? And come back. Thanks.”
According to registered nurse Justin Nixon, who worked at the Lanzer clinics for two years, “fill” means to inject the patient with tumescent fluid. “So he’s leaving the premises while a patient in his care is being operated on.”
On message
In another message, in October 2020, Aronov tells nurses, “New blanket rule: I don’t want any scripts sent in my name for patients I’ve never met or aren’t the primary doctor. That means no scripts in my name for Brisbane or Sydney patients anymore.” It is illegal for nurses to write scripts.
In an audio message to staff, posted after a pharmacist calls to say she received a number of questionable scripts and was told “the nurses write the scripts”, Aronov says: “Do you guys realise that’s fraud. You are putting your own licence at risk.
“From now on there are some new rules.”
On November 29 last year, AHPRA banned Aronov from performing all types of cosmetic surgery and ordered him to remove any social media posts that related to surgery after this masthead’s investigation in October.
It allowed him to continue to work as a GP if overseen by an AHPRA-approved supervisor.
This decision came a month after “Cosmetic Cowboys” aired and 10 days after he performed a tummy tuck and liposuction on 42-year-old Tina Lombardo, who nearly died and is now the lead plaintiff in a class action against the Lanzer group. The morning after surgery Lombardo was rushed to ICU when her partner found her foaming at the mouth.
Her procedures, including a tummy tuck and liposuction of 5 litres of fat, cost her $30,000. But her subsequent treatment in hospital over 11 days cost the taxpayer at least $50,000.
A move by AHPRA to force Aronov to remove social media posts related to his surgeries was curious given it would impact the agency’s ability to monitor videos as part of its continuing investigation.
Johnstone and Fraser captured videos by Aronov doing a tummy tuck outside a dedicated operating theatre, and Lanzer and another doctor parading a patient dripping blood from her wounds after 4 litres of fat were removed in a side room.
Aronov appealed the agency’s decision to restrict his work, claiming direct supervision was tantamount to suspension and was draining him financially.
On June 30, the Victorian Civil and Administrative Tribunal (VCAT) agreed with Aronov and wound back his restrictions. It means he no longer needs to be directly observed by a supervisor during patient consultations as a GP.
This was despite the judgment acknowledging AHPRA was still assessing several complaints including directing nurses to complete blank (signed) scripts, poor hygiene and control practices as well as post-operative complications.
Aronov said in an affidavit quoted in a VCAT appeal that in the past few months he had done some “serious introspection” and “personal growth” and completed a workshop into different approaches to communication by doctors and patients and where they clash.
One of his patients, Jackie M, is appalled by the decision. In December 2020, she underwent liposuction on her neck and the pain was excruciating. “I was crying in agony and he didn’t stop. And he just kept punching at the same place … I couldn’t get up and run away,” she says.
Jackie M underwent liposuction by Dr Daniel Aronov and says she lives with nerve damage as a result.Credit:Eddie Jim
She says she was refused pain medication and ended up with nerve damage to her face, which has left her mouth and other parts of her body disfigured and lopsided. “I live daily with the discomfort. It feels like it has destroyed my confidence and my career prospects. Sometimes I feel like a monster.”
In May 2021– six months before Aronov operated on Lombardo – Jackie lodged a complaint with AHPRA asking the regulator to investigate. It has still not reported back.
“It’s really quite unbelievable that despite all the pain that’s been caused, all the victims, all the undeniable proof of wrongdoing, that AHPRA is still dragging its feet, still reluctant to acknowledge the severity of what these doctors have done,” she says.
“AHPRA has somehow decided that a doctor who has shown no respect for patients during cosmetic surgery, can still be trusted to act appropriately as a GP. It makes no sense.”
AHPRA oversees 15 boards, including the medical board, the state regulators and dozens of other public and private regulators.
States have different rules. In Victoria, it is illegal to take more than 250ml of fat in liposuction in an unregistered facility. In NSW and Queensland, it is up to 2.5 litres.
“When you’ve got two regulators that are basically both responsible for monitoring and prosecuting the same offence, neither will necessarily do it and some people will fall through the gaps, and that’s what’s happening,” Faux says.
Faux believes AHPRA is too lenient on doctors doing the wrong thing. She says Aronov should not be allowed to practise medicine. After watching some videos, including a series of surgeries in an unregistered facility in Pitt Street and a tummy tuck conducted outside a dedicated operating theatre in a day hospital, she was shocked he was still practising.
“So what you are seeing there is someone having their abdomen sliced hip to hip in what looks like an office. So that’s outrageous. And in my view that is a major departure from accepted professional standards,” she says.
“I can’t believe that that doctor is still practising medicine in any shape or form in this country, given what you have showed me. I cannot believe it.
“If that does not constitute professional misconduct, I don’t know what does. He’s slicing someone’s abdomen open in an office.”
Faux believes AHPRA also went easy on Dr Reza Ahmadi. “He liposucked someone’s liver multiple times. He was incompetent, working out of scope, unsafe, and yet, we allow him to continue to practise as a GP? What will it take before we say ‘we need to get these doctors off the street’?”
In April, AHPRA banned Ahmadi from doing cosmetic surgery but allowed him to work as a GP, which as regulatory specialist Andy Schmulow says, doesn’t make sense.
“But he is only a GP. Where is the punishment in restricting him from acting as a surgeon when he isn’t qualified as a surgeon? Where is the punishment for what he has already committed?”
One patient had a BBL and liposuction with Ahmadi in late April and ended up in hospital with sepsis. Ahmadi drove her to the hospital when she continued to lose blood. On arrival, she was given multiple blood transfusions and had a lengthy stay.
Another patient who had a BBL and liposuction in June 2021 developed cellulitis in her left knee. “It got to the point where I could not walk, had extreme fevers, extreme pain, weakness and confusion,” she says.
When the infection spread to her thigh she went to Box Hill Hospital where she stayed for several days.
A month later, in July, a patient had liposuction with Ahmadi and ended up in hospital with borderline septic shock. “It looked like a shiny, day hospital but it was anything but clean,” she says.
Professor Ashton reported Ahmadi to AHPRA in December 2021 in relation to his treatment of Keisha Amoah, including his failure to call an ambulance when she was crying out for one after he liposucked her liver.
Keisha Amoah was drawn in by social media content, but her cosmetic surgery reality tells a different story.Credit:Simon Schluter
In March, Cosmos head office also reported him and alerted the regulator to a number of cases of patient hospitalisation and surgeries during lockdown.
“The punishment delivered upon these people, who have hurt and maimed people, is so grossly inadequate. I can’t square that circle. I can’t make out how it’s allowed to continue,” Ashton says.
Call for a royal commission
In a bombshell move, shortly after Ashton appeared on 60 Minutes, the Victorian Department of Health raided him. “They had received an anonymous handwritten note alleging that I had been operating illegally during the lockdown of the most recent COVID period,” he says.
Months before the raid on Ashton, AHPRA and the Department of Health were alerted to serious problems at Cosmos in Melbourne. Yet they didn’t raid the clinic until two weeks after the 60 Minutes story – and eight days after Ashton.
Registered nurse Justin Nixon, who worked at the Lanzer clinics and first blew the whistle on the dark side of cosmetic surgery 10 months ago, is also astounded by the lack of action from regulators.
“Most of the regulators, I’ve had to call them up,” he says. Nixon says he had to organise some of the nurses at the Lanzer clinics to get in contact with AHPRA because they didn’t seem to be interested in doing it themselves. “It seems that they don’t want to pick up the phone.”
AHPRA’s CEO Martin Fletcher was invited to be interviewed on multiple occasions but declined.
Next month AHPRA will release the findings of an inquiry into cosmetic surgery, but the industry is concerned it will go the same way as other inquiries, a set of recommendations that gather dust in a drawer.
It has prompted calls for a royal commission. “We need an independent, objective inquiry into cosmetic surgery. I can’t see how any inquiry can achieve that unless it’s a royal commission,” Ashton says.
Fels also believes time is up. “There needs to be a serious royal commission or serious public inquiry into the whole situation, starting with the culture at AHPRA, also looking at the law, also at the buck-passing between federal and state regulation,” he says.
Patients such as Jackie M also believe it’s time for a change. “In Australia, you think you’re protected when you walk in the doors of any medical centre, including cosmetic surgeries,” she said. “What I learnt the hard way is that currently, you’re not. And AHPRA, up until now, has not been a voice or protector for the victims. It has enabled the perpetrators. That should be sufficient for all of us to say enough.”
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