Making The Cut

Sydney Morning Herald

Thursday May 1, 2008

Words Valerie Lawson

Throw out those jars of wrinkle cream - jabs, nips and tucks are the keys to eternal beauty, according to those who do it for a living.

THE concept of ageless beauty is a marketable commodity. Marketers promote a magical suspension of time. Consumers buy their promise: they will not age - at least for a while - but remain frozen, like the fairytale characters Sleeping Beauty or Snow White in her glass casket.

Whether you pursue the dream or reject it, the industry selling transformation through cosmetic procedures is growing bigger and more complex by the day. In the 21st century, the promise of hope in a cosmetic jar is no longer enough. The superficial has yielded to the subterranean; to the subdermal; the "work".

At the high end of the price scale, Australians pay up to $30,000 for a full facelift and, at the other end, $300 to $700 for muscle relaxant treatments (Botox, Dysport) that keep wrinkles at bay for a few months.

Those jabs of botulinum toxin help to boost Australian sales of Allergan (maker of Botox) by 26 per cent a year, and at the same rate for Dysport, manufactured by the French company Ipsen.

Sydney plastic surgeon Dr David Caminer says the difference between the price paid for the vials of those products by doctors and that paid by patients is "more than a few hundred per cent". But patients are also paying for the skill of the injector - and that can vary.

Dr John Mahony of Peach Cosmetic Medicine in Paddington says he uses 20 Botox units to treat frown lines on a man's face. That equals "a shade less than a nanogram". A nanogram is a billionth of a gram. The treatment would cost the patient $340.

Allergan executives in Sydney were not available to discuss Botox marketing and sales. A voice message left for a company executive resulted in a return call from the company's public relations firm, Burson-Marsteller, whose staff member said all such details were confidential.

But Allergan staff have told Melbourne's Dr Howard Webster, the president of the Australian Society of Plastic Surgeons, that "Australians have taken to Botox like they did to video recorders. Australians take up new technology rapidly ..."

As for more invasive treatments, demand for cosmetic surgery is "unquestionably increasing", Webster says. "I worked in the US in the 1990s and I would think that per head of population, Australians use [surgery] at least as much as the US.

"In our parents' generation, less than 1 per cent of the population had cosmetic surgery. Look at the current generation. Seven per cent of the female population aged 40 to 65 have had some sort of procedure. In our children's generation, 70 to 90 per cent will have some kind of procedure.

"We are the generation with a certain stigma [about it]. They will proudly display it."

Webster points to a recent study of 7000 respondents conducted by Mission Australia which found "40 per cent of teenagers said they would have it [cosmetic surgery] done if they could. The younger generation sees cosmetic surgery as part of wellbeing."

Webster estimates that about 40 per cent of Australia's 267 plastic surgeons perform cosmetic work and, of those, each doctor does between 200 and 500 procedures a year. But no one really knows the scope of the business in Australia as procedures are not covered by Medicare, there is no requirement to be referred by a GP and, as Webster says, "no one has an interest in making it public".

The demand stems from more intensive marketing, improvements to procedures - meaning less downtime - easier access to all kinds of treatments and a huge expansion in those providing treatment, particularly those promoting themselves as "cosmetic surgeons", as opposed to plastic surgeons.

Paid advertising is minimal in the main media but editorial on makeovers abounds and the internet is an Aladdin's cave of sites. A search for "cosmetic plastic surgeons NSW" yields at least 25,000 results. As well, many doctors recruit public relations consultants or reach new and existing customers with newsletters.

A newsletter of Bondi Junction surgeon Dr George Marcells explains that surgery must be contemplated carefully, but "luxuries like a limousine service can add another dimension - helping you to feel special".

Dr Steven Liew of Darlinghurst has recruited Burson-Marsteller to promote his "Sydney Lip" procedure, while Dr Garry Cussell uses Heusler Public Relations to promote his Facial Rejuvenation Clinics in Sydney.

The current issue of the quarterly Australian Cosmetic Surgery Magazine is a 268-page glossy compendium of "before" and "after" shots along with many articles written by doctors who have advertised in the magazine. Demand is stoked by such TV shows as Extreme Makeover, The Swan, I Want A Famous Face, 10 Years Younger and, in Australia, by Ultimate Transformations, Body Work and The Body Specialists. A new Australian show is said to be in the wings, featuring Bondi Junction surgeon Dr Warwick Nettle.

In her new book Skintight: An Anatomy of Cosmetic Surgery, the Sydney academic Meredith Jones writes that "often gruesome narratives and pictures appearing regularly in various media serve to de-sensitise and initiate a formerly surgical-virgin audience so that cosmetic surgery is no longer associated with danger ... from the mid-1990s, cosmetic surgery began to be repositioned as something normal people could have, something you didn't have to be psychologically compromised to desire ... it is now seen as a means to improving mental wellbeing and as part of the continuing development of the self."

Webster regards marketing as "an ethical minefield". Cosmetic surgery "requires marketing" but "the problem with marketing is that you have to create points of difference to get patients. There's very little that's new" but there is a great deal of advertising for "new" procedures.

One way to build a practice is to "harvest". A scout, such as a nurse, visits beauty therapists' rooms to inject fillers and suggests to clients that more invasive cosmetic work by a doctor (with whom he or she has an association) could produce even better results.

The cosmetic transformation industry changed more than a decade ago with the availability of less invasive techniques, using muscle relaxants, fillers and IPL (intense pulsed light) lasers.

"The work we do now is more subtle, safer, easier, less expensive and less invasive," Mahony says, "so you don't have to wait for the right time for the big facelift."

In the '90s, lasers promised to remove wrinkles without surgery but the downside of the "ablative" lasers of the day included red and raw skin, long-term problems such as loss of pigment, scarring and a risk of infection. Essentially, skin was being vapourised with the epidermis removed and the laser penetrating to the dermis.

Now, non-ablative lasers send light pulses into the dermis while leaving the epidermis intact. They offer the promise of tighter skin but many dermatologists are still waiting to be convinced that non-ablative technologies produce significant benefits.

As for plumping the skin, collagen injections, which required allergy testing, have been cast aside by injectable dermal fillers such as Restylane, Esthelis, Juvederm, Radiesse and Sculptra.

Supplementing the use of fillers are physicians-only cosmeceuticals sold by physicians such as Dr Jan Knight, whose two-year-old clinic Intelligent Ageing is in a Mosman street where yummy mummies sit at cafes, with babies at their side.

Knight relinquished her practice as a GP when she tired of treating earaches and "being the doom and gloom merchant ... I thought, 'If I have to do this for the rest of my life I'll slash my wrists."'

Now she feels rewarded, emotionally and financially. Her clients spend an average of $3000 to $5000 for fillers, muscle relaxants, laser treatment and various products she sells to restore faces to the desirable shape, that is a "young person's triangle", with big eyes, smooth cheeks and a firm jaw. For her, the results can be satisfying. One patient, Renu Manchanda, consulted her after being "bitten by IPL", which left tattoo marks on her skin.

Manchanda, an Indian woman who works in the public service, suffered sun damage due to her past history of outdoor volunteer work. A black spot on her nose "got bigger and bigger and looked very bad". A beauty therapist in Sydney's north-west suggested five IPL sessions would solve the problem. After one treatment, Manchandra's nose peeled, leaving dark, tattoo-like marks: "I was very depressed. People would look at me and say, 'What happened to you?"'

Through creams and more treatment with Knight, the marks are gradually fading. Another patient of Knight's came to her after suffering from laser-induced "zebra stripes and hypopigmentation". A third patient was Stan Zemanek, whose drug treatment for cancer created deep facial marks. "We tried peels on him, made him up and got him back on TV. He loved it," says Dr Jan, as she is known.

Similarly, Mahony swapped his role as a GP for cosmetic work (including liposuction) when he noticed how few male patients at his former surgery, at Newtown, in Sydney's inner-west, had chest hair.

"I saw an ad in a medical journal about laser hair removal and I thought, 'Who could make a go of that if I can't?' I thought, 'This is interesting. I get to play with a great big toy ... and I have grateful patients."'.

He was aware of the financial risks. The fitout for his clinic cost $200,000 and with the purchase of about $700,000 of equipment, it is "a roll of the dice".

Doctors such as Lawrence Ho (Mayerling Skin Renewal System) and Geoffrey Heber (founder of Ultraceuticals) offer their own line of cosmeceuticals. Nettle does not have a product range yet but he is involved with a range of scented candles and perfume.

As for traditional cosmetics, anything you bought about five years ago over the counter is "virtually useless", he says, but today's cosmetics have active ingredients such as vitamin C. "People have been seeking this 'holy grail' of non-surgical intervention for years and it's totally understandable," Nettle says. Surgery is a "confronting and scary thing but at this stage nothing [but surgery] works quite as well, nothing delivers the bang for the buck."

Nettle and Caminer have noticed more demand for lower body lifts from patients who have lost a lot of weight through gastric banding. However, Nettle says, "anecdotally, you hear of growth in practically every area".

Caminer, who sees between 500 and 600 new patients a year at his practice in St Vincent's Medical Centre, recently treated a woman who lost 60 kilograms through gastric banding. "I got rid of the loose skin on her tummy and gave her bigger boobs and got rid of the 'bingo wings' [flabby upper arms]."

He has also treated a woman whose first facelift in her 20s was followed by an operation on her jaw in Thailand where "they chopped the bottom of her jaw away". He fixed the jaw.

Cheap cosmetic surgery "holidays" to Asia often end badly - the wealthy prefer to go to New York for their facelifts and hide out before returning to Australia "refreshed".

Nettle believes "the single most amazing change" in facelift technique is due to Botox, not in itself, but in the way in which it gave doctors a different way of seeing how the face ages, that is, through repeated muscle movement. Instead of merely pulling on facial skin and muscle, doctors are working on pumping up the volume and "moving more to what we can do with the muscles as well ... what they are doing and the way they are ageing".

Caminer says demand by men for cosmetic surgery remains relatively low - "10 to 15 per cent" of his patients, who want skin reduction after weight loss, eyelid and nose surgery and calf implants. Men represent 15 to 20 per cent of Nettle's practice and were "branching into facelifts" as well as eyelid work - such as a procedure Kerry Packer had, which was performed by a former boss of Nettle's, US surgeon Michael Hogan: "He did one operation in Australia ... and that was Kerry Packer. He was a friend of the family."

The biggest change in cosmetic work in the past few years has been improvement in patient management, Webster says.

"Surgery has become much more accessible, easier to do, with improvements in local anaesthetic and equipment."

The prevalence of day surgery has opened the market for "doctors of all kinds" performing complex surgery under minimal anaesthesia in facilities that are not registered as surgery centres, he says. As with most plastic surgeons who have trained with the Royal Australasian College of Surgeons, Webster is critical of the nine-year-old Australasian College of Cosmetic Surgery, as many of its members are physicians who specialise in cosmetic procedures.

"Cosmetic and plastic surgeons - they're at loggerheads," Caminer says. "Most of the cosmetic guys are only in it for money ... they formed their own college ... their own company.

"Most cosmetic surgeons will do lipo, breast [augmentations], easy-ish facelifts and eyes. You don't find them doing noses, which are difficult, or breast reductions or breast lifts."

However, cosmetic surgeons maintain their work is "as good [as] or better than that of the plastic surgeons", as Meredith Jones writes in Skintight.

They "insist that plastic surgeons are merely lobbying for a monopoly on a highly lucrative market".

One doctor, not a plastic surgeon, says "the cosmetic guys love doing breasts. It's easy money for them." Caminer says: "The cheaper you make it, the more young girls flood your rooms. They are about cost. Age 19 is fine for me; 16 is a different story."

NSW Health Minister Reba Meagher recently announced a cooling-off period for girls under 18 seeking cosmetic surgery but the demand by women who have hardly reached middle age continues to grow.

"The age of people seeking cosmetic surgery is getting younger," Nettle says. "In the first few years I didn't see anyone under 44 coming in requesting a facelift. Now we frequently get people in their 30s."

Dr Gabi Creswell, a GP and cosmetic physician in Moree, sees mainly "empowered older women seeking these [less invasive] treatments".

Post-50, menopause is huge, when ovaries switch off and the amount of collagen changes. "At 60-plus, we're dealing with the baby-boom generation - empty nesters [who think it is] me time."

Robyn Neville, a beauty therapist in Mascot, was 46 last November when Nettle did her facelift. She thought she looked 10 years older: "I had crows' feet; frown lines. Eventually it was all going to join up, like a Gregory's street directory. My appearance gave me a sense of sadness."

At first, her husband said, "Robyn, grow old gracefully", but in the end, "he said he would support me all the way".

In a 41/2-hour operation, "I had both upper and lower lids done, cuts above each eyebrow and a small chin implant. My cheeks were lifted and there were cuts around edge of ear and the whole back of the ear. I had dermabrasion on the top lip."

Was she nervous beforehand?

"Not one bit. I said, 'No, bring it on.' The film crew was there."

Neville, it seems, is Nettle's poster girl. She received a discount on her $29,000 surgery in return for being filmed for an American website on cosmetic surgery.

"People go, 'Oh my God, Robbie,"', surprised and mostly full of praise for her new look - although the staff at her dentist's surgery were "standoffish".

Nettle says: "There's this pent-up demand. There are two aspects: helping people realise their goal and be the best they can be. And there's this whole vanity thing, doing things on a whim, and that can end in tears.

"My grandfather ... was an intellectual man and when I [die and see him] he might say, 'What are you doing?' But you have to take our own path. The thing I like is that this area is exploding.

"Conventional plastic surgery is not changing as quickly and dynamically as this area. It's market driven, isn't it?"

Million-dollar babes

In Australia last June and July, the Cosmetic Physicians Society of Australasia surveyed 2211 respondents about their minimally invasive cosmetic procedures (Botox, dermal fillers, lasers, microdermabrasion). It found that 10 per cent of respondents had had one or more cosmetic procedures, while about 60 per cent had thought about doing so.

One-third of respondents had spent between $1000 to $3000 and 10 per cent more than $5000 on non-surgical procedures. Muscle relaxants were the first choice of both men and women, with 38.5 per cent of respondents having the treatment. Respondents often had more than one procedure, with the result that 34.6 per cent had dermabrasion, 29.1 per cent laser and IPL hair removal, and 25.2 per cent dermal fillers to plump lines and lips.

Of respondents aged 29 and below, almost a quarter had muscle relaxant treatments compared with more than half of 40-49 year old respondents and 60 per cent of respondents aged 60 and above. Forty per cent did not confirm their doctor's credentials before they underwent any non-surgical cosmetic procedure.

The society announced last month that Australians spent $300 million on such procedures in 2007, although that figure is an estimate.

What it costs

Upper eyelids:

$3000 to $6000

* Upper and lower eyelids:

up to $8000

* Breast augmentation: up to $12,000 but some surgeons may charge $5500 for shorter operation

* Facelifts: depends on what you include - between $10,000 (my surgical fee $8000) to $15,000 plus $2500 anaesthetics (Dr Caminer)

* Mini-facelift in office: about $8000

Major facelift: about $20,000 (Dr Nettle)

(Prices, including surgeon, anaesthetist and facility)