MEREDITH JONES, AUTHOR “MAKEOVER CULTURE”: Western culture is obsessed with breasts, absolutely obsessed. At the moment, breast augmentation is massive. It's certainly taken off. We don't have to accept what nature throws at us, just as we don't accept that nature throws diseases at us - we try and counter it.

DR DANIEL FLEMING, AUSTRALASIAN COLLEGE OF COSMETIC SURGERY: Silicone, on the other hand, feels like this.

DONNA NEWPORT: OK. That one's better.

LEANNE HEZLETT: I've wanted to do it since I was 19, 18. So it's played a big part on my mind.

DR PETER HAERTSCH, PLASTIC SURGEON (OPERATING): What have I written down in terms of the implant size?

JONATHAN HOLMES: No one knows how many breast augmentations are performed every year in Australia, and no-one knows how many go wrong. After three operations on her breasts, this woman was devastated by the result.

“JULIE”: Two fried eggs, these two eggs. That's the original breast tissue, and this is how the implant's sagging below the original breast line.

JONATHAN HOLMES: Each year, tens of thousands of cosmetic procedures, from Botox injections to major surgery, are performed in day theatres and doctors’ rooms around Australia. It's a growth industry, and a largely unregulated one.

ASSOC. PROF. MERRILYN WALTON, FORMER HEALTH CARE COMPLAINTS COMMISSIONER, NSW: When it comes to rooms, where now the majority of cosmetic surgery is done in rooms, or private businesses, there are no standards or requirements.

JONATHAN HOLMES: So it's not actually.

ASSOC. PROF. MERRILYN WALTON, FORMER HEALTH CARE COMPLAINTS COMMISSIONER, NSW: It's totally unregulated.

DR JOANNA FLYNN, MEDICAL PRACTITIONERS BOARD OF VICTORIA: Doctors are professionals. They are expected to do the right thing.

JONATHAN HOLMES: But in these areas where there's enormous amounts of money to be made, can we go on relying on doctors to do the right thing?

DR JOANNA FLYNN, MEDICAL PRACTITIONERS BOARD OF VICTORIA: If we can't rely essentially on doctors to do the right thing,
then we're in deep trouble.

JONATHAN HOLMES: In traditional healthcare, we're used to believing that doctor knows best, but, if we volunteer to go under the knife for the sake of our looks, are we patients, or customers? Tonight on Four Corners, let the buyer of beauty beware.

In a shopping mall on Queensland's Bribie Island, it's the state finals of the Miss Teen Australia contest.

EMMA MASTERS: I guess ever since I was little I've always been strutting. I've always had heels, you know, the plastic Barbie doll heels. I've just always loved it.

ANGELA HILL: I've always been a fashion queen, all through my teens.

TAMIKA CHESSER: Always a drama queen, liked getting dressed up.

JONATHAN HOLMES: They're growing up in a world where you can change the looks that you're born with for looks you can buy - not that these girls would dream of doing it.

EMMA MASTERS: It's not a good thing, for starters, because I know kids 16 and up are getting cosmetic surgery now - breasts done, eyes, lips, you know, all that, and I think that's a no-go zone, but for the older people I think that's, that's their choice.

JONATHAN HOLMES: Why do you think it's a no-go zone?

EMMA MASTERS: Because they haven't really found themselves yet, and they're creating themselves into someone that they don't even know.

ANGELA HILL: Because, like, in that younger age bracket, you're supposed to be having fun. You're not supposed to be fussing about the way you look, and, you know, not being able to go to the beach because you don't want your make-up to run - and just be having fun and just not worried about that kind of stuff.

JONATHAN HOLMES: All very well if you're born beautiful. Less fortunate people know that in 21st century Australia, whether you're 16 or 60, looks matter. We're bombarded every minute of our day by images of unattainable perfection.

MEREDITH JONES, AUTHOR “MAKEOVER CULTURE”: We live in an image-saturated culture where most of the images we see come out of Hollywood. Most of them are faces, and most of them are faces that have had cosmetic surgery. All of us are part of that culture. It's not something that's going to go away.

JONATHAN HOLMES: And what once was private is now public. The proliferating makeover television shows have removed the last vestige of shame from a once-furtive industry.

“ULTIMATE TRANSFORMATIONS”

WOMAN: I would like my teeth done, my - my breasts done.

2ND WOMAN: I would like all of my fat sucked out - after having two kids. Everyone would like to have it done, I'm sure.

JONATHAN HOLMES: These shows are appealing to the same cultural instinct as 'Backyard Blitz' or 'Better Homes and Gardens', says social anthropologist Meredith Jones. She's working on a book called 'Makeover Culture'.

MEREDITH JONES, AUTHOR “MAKEOVER CULTURE”: ‘Makeover Culture’ refers to all sorts of things that we feel the need to make over. So those could be buildings, houses, our careers, our bodies and faces, our gardens, our homes. And I think that is actually what cosmetic surgery's about. It's not - it's not about achieving a point of - of beauty that's static and final and definite. It's actually about showing that you're a happening individual in makeover culture, and - - -

JONATHAN HOLMES: You're always getting better?

MEREDITH JONES, AUTHOR “MAKEOVER CULTURE”: Exactly, that you're in a process, a continual process of self improvement.

JONATHAN HOLMES: By those standards, Joan Wilkinson is certainly a happening individual. She's a cosmetic surgery veteran. She's had face lifts and eye jobs and breast jobs before. And tonight she's off to Kuala Lumpur, for a holiday and makeover rolled into one.

JOAN WILKINSON: I would like my face done, my eyes, and maybe my nose straightened a little bit. My chin - I've got fat under the chin - I'll get rid of that, maybe have my breasts made a bit bigger.

JONATHAN HOLMES: Bigger?

JOAN WILKINSON: Yeah, bigger. And I've got a pop-up bra on at the moment.

JONATHAN HOLMES: OK.

JOAN WILKINSON: So that helps.

JONATHAN HOLMES: Her getaway is being organised by an outfit she found on the web, and she can't wait.

JOAN WILKINSON: They're at least half to three times cheaper than here, and their hospital is a really top standard hospital. I've checked on that on the Internet.

JONATHAN HOLMES: She's well into her 60s but feels 10 years younger, and wants to look it too.

JOAN WILKINSON: A lot of people like to renovate their house, decorate. I like to renovate me and decorate me. I mean, I don't think it's vain because - I mean, people what say I'm vain, I mean, they have their hair coloured, they wear high heels, they wear bras, they put make-up on; it's still announcing themselves. So I consider this as announcing me, I hope.

JONATHAN HOLMES: In Australia, the craze for cosmetic medicine has produced a new breed of doctor-cum-entrepreneur. Almost a decade ago, the strictures on medical advertising were relaxed.

Now the makeover men appear on the TV shows, advertise in the specialist magazines and fill their websites with alluring pictures of actual patients.

In every capital city, specialist clinics have sprung up to cater for the new demand. Likely as not, the receptionist will double as a walking advertisement.

RECEPTIONIST: I've had Botox and I have breast augmentation.

JONATHAN HOLMES: And when patients or clients come in here do you tend to let them know sometimes that you've had this yourself?

RECEPTIONIST: Yes. Yep, yep. Certainly. I mean, that's part of the – part of the deal of working in a cosmetic surgery. I'm certainly very comfortable with it all, and I have a lot of friends who have considered having different procedures done.

JONATHAN HOLMES: What are the most popular procedures here at the moment, do you think?

RECEPTIONIST: At the moment, breast augmentation is massive. Liposuction has always been a very popular procedure.

DOCTOR (OPERATING): You can see it's almost pure fat coming through the tubing.

JONATHAN HOLMES: Liposuction is not a pretty procedure to watch.

DR JOSEF GOLDBAUM (TALKING AS HE OPERATES): And this is basically a mini-vacuum cleaner, nothing more, nothing less, just a mini-vacuum cleaner, and I just have to move it backwards and forwards to work the fat out, just like moving a vacuum cleaner along the floor.

JONATHAN HOLMES: Dr Josef Goldbaum, whose Melbourne-based company, Liposuction Australia, claims on its website to have a “100 per cent safety record", says sometimes he's embarrassed by his patients' gratitude.

DR JOSEF GOLDBAUM: It's a difficult situation when the patient wants to come and give you a cuddle and a kiss because you've done someone such a good thing for them and they are really happy with you. In Europe, it would be no problem, it would be two, three, four kisses on the cheek, it's accepted. Here, for a patient to come and give you a cuddle, I mean, you know, look out medical board, here come the complaints. So it's kind of, "Thank you. I appreciate your good wishes".

JONATHAN HOLMES: In fact, cosmetic surgery generates more insurance claims than most other areas in medicine. Only obstetricians have to pay higher premiums than cosmetic practitioners. And it's a field where hard evidence about the long-term risk of common procedures, from Botox injections to liposuction, is very thin on the ground.

Merrilyn Walton chaired a 1999 New South Wales inquiry into cosmetic surgery.

ASSOC. PROF. MERRILYN WALTON, FORMER HEALTH CARE COMPLAINTS COMMISSIONER, NSW: When we did the literature review for the inquiry, there was absolutely no evidence of the long-term effects or implications of repeated liposuction. There are some side effects that patients are told about, like the fat might depose somewhere else in your body where you didn't have liposuction, but we have no evidence of any of the consequences of these procedures.

JONATHAN HOLMES: Even among practitioners, there are profound disagreements about the effects of liposuction and many other cosmetic procedures. In a newsletter dropped into letterboxes around Melbourne last year, for example, Dr Goldbaum claimed: “Skin is like an elastic band. Once you remove what has been making it stretch, it will soon shrink back again, just like an elastic band.”

The Australian Society of Plastic Surgeons doesn't think that statement's true.

DR HOWARD WEBSTER, AUSTRALIAN SOCIETY OF PLASTIC SURGEONS: Absolutely not, and it's complete nonsense. I mean, anyone that's had a pregnancy will tell you that the skin isn't quite the same when it shrinks back. Now, some people it shrinks back better than other people, but liposuction is simply a procedure to remove fat. The way skin shrinks back is a genetic difference between people; in some it just doesn't shrink back at all.

DR JOSEF GOLDBAUM: Well, it depends on levels of experience and expertise. In my experience, skin always shrinks back, always, without fail, in every possible case, in every age group. There is not one person where skin has not retracted.

JONATHAN HOLMES: So who's to decide who's right? In Victoria, medical advertising is supposedly regulated, both by the Medical Practitioners Board and by the ACCC, the Competition and Consumer Commission. Not that either does much regulating. The board says its powers are inadequate, the ACCC has the power but not apparently the will.

DR JOANNA FLYNN, MEDICAL PRACTITIONERS BOARD OF VICTORIA: We as the board are concerned that there are unreasonable expectations being created in the minds of the public about the treatment that they might be offered by, particularly, cosmetic practitioners. We have a set of advertising guidelines, which we developed some years ago and came into operation in 2004, but our view now is that those guidelines are insufficient and they're not protecting the public in the way that we hoped that they would.

JONATHAN HOLMES: But, as the cosmetic medicine industry has flourished, the ACCC has been more interested in promoting competition than in protecting consumers. It's blocked the Victorian Medical Board's proposed tightening of its advertising guidelines.

So, in a sense, there's a conflict between what the Medical Practitioners Board believes is a standard that should be applied and what the ACCC believes is a standard that should be applied?

DR JOANNA FLYNN, MEDICAL PRACTITIONERS BOARD OF VICTORIA: That's correct. There is a conflict.

“SARAH”: It's quite bizarre-looking at the moment.

JONATHAN HOLMES: This dreadful result of liposuction was the work not of Dr Goldbaum, but of another doctor who advertises widely in Victoria. We'll call the patient Sarah, though it's not her real name.

“SARAH”: This particular doctor's been in the media a lot, promoting that he's an expert in this field. He's done a lot of television and magazines and stuff, and he certainly sounded impressive.

JONATHAN HOLMES: But the plastic surgeon to whom Sarah recently went for a second opinion is horrified.

DR PETER CALLAN, PLASTIC SURGEON: When I first saw the result of what she told me was liposuction, I was appalled. That is not the result you would expect from well-performed liposuction.

JONATHAN HOLMES: Have you seen that kind of thing before?

DR PETER CALLAN, PLASTIC SURGEON: No, not really, not to that extreme. I certainly haven't. She's had all the fat removed from under the skin of the stomach. That's poor surgery, without doubt. That’s - whoever's done the surgery has taken far too much.

JONATHAN HOLMES: Dr Callan's prognosis for Sarah is depressing.

“SARAH”: All he can do is really cut out the area, so I'll be left with a scar from my, sort of, chest down to under my belly button.

JONATHAN HOLMES: But Sarah says she can't afford to take the original doctor to court.

“SARAH”: To find out whether you have sufficient physical or emotional damage costs you about two or three thousand in assessments before they'll even take on the case. I don't have that kind of money.

JONATHAN HOLMES: Have you made any formal complaint to the Health Care Commission or - - -

“SARAH”: No, no, see, I don't tend to think that way, and I probably should.

JONATHAN HOLMES: In fact, probably only a small minority of unhappy cosmetic customers make formal complaints.

ASSOC. PROF. MERRILYN WALTON, FORMER HEALTH CARE COMPLAINTS COMMISSIONER, NSW: It's not the sort of thing you'd go to the Medical Board or the Health Care Complaints Commission, or indeed any commission, and say, you know, "I went to have a facelift and I got a post-operative infection and now my face looks worse." I think it's more natural they'd go back to the doctor who did it and say, "You botched my job and I want some compensation, or fix it."

JONATHAN HOLMES: In the absence of a strong-minded regulator, the doctors are fighting it out among themselves, and some of the fiercest battles right now are in Queensland.

The Gold Coast is reputedly the breast implant capital of Australia. If you want to fill out a bikini the way they do in the magazines, this is the place to come.

Leanne Hezlett has travelled up to Surfers Paradise from Coffs Harbour in New South Wales.

LEANNE HEZLETT: Because I'm flat chested and can't fill a 10A bra. My mother and my aunty have had breast implants done, so - and I've seen the outcome of how they look, and one of my girlfriends has had hers done, so - - -

JONATHAN HOLMES: But you've waited a while, I mean, you're, what, late 30s now or - - -

LEANNE HEZLETT: Three children later and money and the mortgage is down, so that plays a big part.

JONATHAN HOLMES: Leanne Hezlett has chosen the services of Pamela Noon, celebrity veteran of scores of procedures, and cosmetic entrepreneur, to organise her operation. Noon's paying clients are the doctors and surgeons who fly in to her Gold Coast clinic from the east coast capital cities.

DR PETER HAERTSCH, PLASTIC SURGEON: Good afternoon, Leanne.

DR PETER HAERTSCH, PLASTIC SURGEON: Peter Haertsch is my name. Leanne, how old are you, love?

LEANNE HEZLETT: 38.

DR PETER HAERTSCH, PLASTIC SURGEON: And are you married?

LEANNE HEZLETT: Yes.

JONATHAN HOLMES: Leanne Hezlett only meets the man who'll operate on her breasts the day before the operation.

Professor Peter Haertsch is an eminent Sydney plastic surgeon who operates on the Gold Coast for one day a month.

DR PETER HAERTSCH, PLASTIC SURGEON: An infection in the breast pocket is potentially a very serious one, in that you would lose the implant.

JONATHAN HOLMES: As Dr Haertsch runs through a daunting catalogue of possible complications, he's brusque and to the point.

DR PETER HAERTSCH, PLASTIC SURGEON: This is an elective procedure, and I cannot - try as hard and as much as I want, I cannot guarantee that this will be trouble free.

LEANNE HEZLETT: Right.

DR PETER HAERTSCH, PLASTIC SURGEON: I cannot guarantee that. If you have any doubt in your mind, you don't go ahead, you resolve those doubts.

DR DANIEL FLEMING, AUSTRALASIAN COLLEGE OF COSMETIC SURGERY: OK, Donna, you've put this crop top on and what we're going to do is put some implants inside there and you can look in the mirror and get an idea of the kind and size and shape you would like - - -

JONATHAN HOLMES: An hour up the freeway, in a Brisbane consulting room, Donna Newport is meeting the man who'll be putting implants in her breasts tomorrow.

DR DANIEL FLEMING, AUSTRALASIAN COLLEGE OF COSMETIC SURGERY: And if you turn sideways, that'll give you an idea.

JONATHAN HOLMES: She chose Dr Daniel Fleming after scouring the websites of cosmetic surgeons.

DONNA NEWPORT: Just research, research, research, research. I thought it was a pretty big deal, and I wanted to find the best, and he had the best resumé out there and the most - - -

JONATHAN HOLMES: How did you judge that, when you say the best resumé?

DONNA NEWPORT: Experience and how long he's been doing it, so I went from that.

JONATHAN HOLMES: In fact, though neither of them seem aware of it, Donna Newport and Leanne Hezlett are being operated on by champions of two bitterly feuding surgical armies.

Professor Peter Haertsch, like all qualified plastic surgeons, is a Fellow of the Royal Australasian College of Surgeons, known in the profession as RACS. Earning the right to put FRACS after your name involves at least eight years’ arduous post-graduate training. Many plastic surgeons do a further two years overseas.

RACS runs the only surgical training course in Australia recognised by the Australian Medical Council. In some states - including Queensland - only fellows of RACS are entitled to call themselves surgeons. But in most states – including Victoria and New South Wales - it's different.

BETH WILSON, HEALTH SERVICES COMMISSIONER, VICTORIA: Most members of the public would think that someone calling themselves a surgeon would have years of training, because it is such an invasive thing to do, however, it's not unlawful for any doctor to call themselves a surgeon, and many of them in the cosmetic area do just that.

JONATHAN HOLMES: And, whatever they call themselves, there's nothing to stop any doctor, anywhere in Australia, from performing surgical procedures.

Dr Daniel Fleming is not a fellow of RACS. He is a founding fellow of the Australasian College of Cosmetic Surgery. Though the college has not been recognised by the Australian Medical Council, and may never be, Dr Fleming claims that its fellows are better cosmetic surgeons than many who have trained through the RACS system.

DR DANIEL FLEMING, AUSTRALASIAN COLLEGE OF COSMETIC SURGERY: Cosmetic surgery is performed almost exclusively in the private system. Surgeons are traditionally trained through RACS in the public system, and there aren't those cosmetic surgery patients in the public system for RACS to give adequate training in cosmetic surgery. They insist that if you are not a RACS surgeon - that you are not qualified to perform these procedures, whereas the big lie is, in fact, they have less training in cosmetic surgery procedures at the time that they obtain their qualification than fellows of the Australasian College of Cosmetic Surgery do.

JONATHAN HOLMES: It's true that Peter Haertsch, for example, spends only a couple of days a month doing cosmetic surgery. His specialty is treating severe burns and performing complex gender reassignments. Breast augmentations, you get the impression, are a straightforward way of supplementing his income.

Dr Haertsch is scathing about those who describe breast augmentation as an art.

DR PETER HAERTSCH, PLASTIC SURGEON: All this business about artistry and that, it's - you know, it's part of the commercial patter. It more or less trivialises the whole thing, and, you know, this is real surgery. It's not - you can end up in the chest cavity if you don't know what you're doing.

OK. We're going to change around - you know, and if you - if you've had a proper surgical training, you can deal with that complication.

JONATHAN HOLMES: Dr Fleming says the College of Cosmetic Surgery completely agrees.

DR DANIEL FLEMING, AUSTRALASIAN COLLEGE OF COSMETIC SURGERY: That's why, before any doctor can even get on to our training program, we insist that they have three years of approved surgical training, approved by our college, in non cosmetic surgery things in the public hospital system, so that they can deal with those kind of complications. And, unless they satisfy those criteria, we don't even let them in to our training program.

JONATHAN HOLMES: The plastic surgeons treat these claims with ill-concealed derision. Dr Fleming and his colleagues, they say, are just GPs with ideas above their station, and the College of Cosmetic Surgery little more than a website set up six years ago by doctors who wanted to get into the lucrative business of cosmetic surgery without doing the hard yards.

Howard Webster is a Melbourne-based plastic surgeon, and a council member of the Australian Society of Plastic Surgeons - the ASPS.

DR HOWARD WEBSTER, AUSTRALIAN SOCIETY OF PLASTIC SURGEONS: Plastic surgeons in this country have been trained in cosmetic surgery for over 30 years. Entry to surgical training in this country is non-discriminatory and widely accessible. You've just got to do 8 to 10 years of really hard work.

JONATHAN HOLMES: In fact, the plastic surgeons have complained to the ACCC that self-styled cosmetic surgeons, especially those who put “Fellow of the Australasian College of Cosmetic Surgery” after their names, are guilty of misleading advertising.

DR HOWARD WEBSTER, AUSTRALIAN SOCIETY OF PLASTIC SURGEONS: We're not claiming that only we should do the surgery, we have no right to claim that, but what does become frustrating is when we try and comply with the guidelines, and people who are not qualified surgeons gain lots of business on unsuspecting people, through, really, making grandiose claims or putting many letters after their names that, in fact, mean nothing.

DR DANIEL FLEMING, AUSTRALASIAN COLLEGE OF COSMETIC SURGERY: Now, you have to understand what the Australian Society of Plastic Surgeons is. It is a lobby group that represents the economic and political interests of those plastic surgeons who choose to belong to it. Now, those aren’t my words, Jonathan. If you look in the small print on their website, that is their raison d'etre.

JONATHAN HOLMES: But does this ferocious turf war between the surgeons actually make a difference to the consumer? Is there any evidence that plastic surgeons make fewer mistakes or get better results overall than so-called cosmetic surgeons, or, for that matter, vice versa?

BETH WILSON, HEALTH SERVICES COMMISSIONER, VICTORIA: Over the years, I've had more complaints about doctors who are not fully qualified surgeons than fully qualified surgeons, but, as I say, the complaints data are misleading. They're only the tip of the iceberg.

DR JOANNA FLYNN, MEDICAL PRACTITIONERS BOARD OF VICTORIA: We don't have data that would support that in a robust way. So - we might have impressions about that, but we don't have a sufficient number of complaints across the different groups for us to get any really evidence-based assessment of that question.

JONATHAN HOLMES: So, the fact is we don't really know.

DR JOANNA FLYNN, MEDICAL PRACTITIONERS BOARD OF VICTORIA: We don't really know. That's correct.

JONATHAN HOLMES: We don't even know what percentage of women who have breast augmentations end up as casualties.

This woman - we'll call her Julie, though again it's not her real name - is one. A slim woman in her early 40s, she had her first breast surgery early last year. She says her surgeon persuaded her to agree to larger implants than she'd originally asked for. The result was a huge disappointment.

“JULIE”: This is the very first operation. You can see the implants are round and large, and it's immediately after, a couple of days after. So, the nipples are still sitting on the halfway line, and, within a couple of weeks, the nipples then moved to about that position there as the implant relaxed and dropped. The pocket that was cut to accommodate the implant was too low. The implant was literally sagging below the original breast line. There was a fold for my natural breast, and the implant sagging below it.

JONATHAN HOLMES: The surgeon agreed to do a second operation and then a third, in rapid succession, to try to correct the problem, but the result was worse than ever.

“JULIE”: This was the third operation I'd had, and we had hoped - I had anticipated we'd be getting close to good here, but you can already see that the nipples are sitting above the halfway line.

That's at rest. The moment I moved my pectoral muscle, this is what happened, two fried eggs - these two eggs. That's the original breast tissue and this is how the implant's sagging below the original breast line.

JONATHAN HOLMES: After months of pain and expense, Julie was left with completely distorted breasts. In February this year, she had the implants removed altogether, to allow her breast muscles to recover.

“JULIE”: I was just absolutely devastated when I woke up in the recovery room, you know, because I looked at my chest then, and there was, you know, two enormous scars, which you'd expect. I mean, we talk about three operations, you know, in quick succession - it's an enormous toll, physically. It's an enormous toll financially. It's an enormous toll in my capacity - for me, my capacity to work, my capacity to be a parent. I mean, it was all I could do, for a year, to get through the day.

JONATHAN HOLMES: To add to her misery, the empty cavities filled with liquid. She had to have drains installed.

“JULIE”: This was what I had to carry around for 10 days after the surgery. I couldn't afford to take any more time off work, so, literally, I had the drains put in one morning, and had to front up back at the office that afternoon, I couldn't take any more time off.

JONATHAN HOLMES: So, where were you hiding all this stuff?

“JULIE”: In a handbag over my shoulder.

JONATHAN HOLMES: Three months ago, Julie had more surgery.

“JULIE”: Considering it's operation number 5, I'm disappointed.

JONATHAN HOLMES: She's had a new pair of smaller implants inserted. The result, she says, is far better than what she had before. In fact, her breasts are now the size she'd originally wanted, but there are still problems.

“JULIE”: What you can see here is a capsule forming, the scar capsule that forms around the implant.

JONATHAN HOLMES: You've got a ripple there in the – it's - it's rippled.

“JULIE”: Yeah. And there's nothing that will make that go away, other than another operation.

JONATHAN HOLMES: So far, Julie has made no formal complaint against the surgeon, nor taken him to court.

“JULIE”: I'd like to think that I could get what it cost me back, but I'm not quite sure, just at this stage - in fact, I know that at this stage, I'm not mentally prepared for it. Maybe a few months down the track, I will be. I mean, I just manage to get through my day without taking on a law case, you know, with a wealthy surgeon.

JONATHAN HOLMES: And it happens that wealthy surgeon is a member of the Australian Society of Plastic Surgeons, and a fully qualified fellow of RACS.

It's the sort of case that gives ammunition to Daniel Fleming and his colleagues of the College of Cosmetic Surgery, in the continuing battle of the surgeons. They've launched a new offensive, over this modest new day surgery in Logan City, south of Brisbane. Before it opened, a number of doctors, including Dr Simon Rosenbaum, applied for operating privileges.

DR SIMON ROSENBAUM: I was invited to apply by the owner of the facility, and I – and I thought, "Great, I'll take the opportunity, and – and I'll apply,” and I was very surprised that I was knocked back.

JONATHAN HOLMES: Dr Rosenbaum has been performing invasive surgery, from facelifts and breast augmentations to tummy tucks, for more than a decade.

DR SIMON ROSENBAUM: I would have done at least 500 of these procedures in the last 10 years or so.

JONATHAN HOLMES: But he's not a fellow of the Royal Australasian College of Surgeons. According to the College, he's just a GP. To get surgical privileges at Logan Surgery Centre, Rosenbaum had to be vetted by a credentialing committee, which included a RACS nominee.

Without even examining Dr Rosenbaum's surgical record, the nominee, a plastic surgeon, persuaded the committee to reject his application. Next day, RACS published a press release on its website, which states, bluntly: “GPs do not have the experience or skill to operate on patients unless it is done under a local anaesthetic.”

Now, the Australasian College of Cosmetic Surgery has made its own formal complaint to the competition watchdog, the ACCC.

DR DANIEL FLEMING, AUSTRALASIAN COLLEGE OF COSMETIC SURGERY: Now, the national standard on credentialing requires that any doctor who applies for any procedural privileges at any private hospital is required to be assessed on the basis of, I quote, "professional competence only". In addition, they are not to be assessed just because they happen to be a member of any professional organisation, college or society, including our own. The representative of the Royal Australasian College of Surgeons hijacked the committee and forced the committee not even to consider the competence of these applicants, unless they were in his club.

DR RUSSELL STITZ, ROYAL AUSTRALASIAN COLLEGE OF SURGEONS: Yes, well, I mean, obviously, that's the claim all the time, that we are trying to be protectionists, but the fact is that you have an obligation, if we're a professional body, and with government, to make sure the standards of care are of high quality.

DR SIMON ROSENBAUM: At the moment, we're on track to do over a hundred of these procedures in this current year.

JONATHAN HOLMES: Dr Rosenbaum maintains that his basic surgical training is excellent and he's learning all the time.

DR SIMON ROSENBAUM: There is so much good teaching information around, that anyone with basic surgical skills can up skill themselves to do more and bigger procedures. I've just brought some things in here, just to illustrate the point. I've just received this in the mail, which is a book, together with a DVD, which is basically a step-by-step instruction manual on how to do a particular type of surgical procedure. Here is a book on a very straightforward type of facelift procedure, that comes with an instructional DVD. Now, this is not suitable for a physiotherapist to pick up and start doing procedures, but what it does is it gives someone with basic surgical skills the ability to do more invasive procedures in an extremely reliable and comprehensive way.

DR HOWARD WEBSTER, AUSTRALIAN SOCIETY OF PLASTIC SURGEONS: Well, the thing is that you train as a surgeon or not. I mean, an analogy might be, you want to become a commercial pilot. Now, if you do a commercial pilot training, you learn to fly all different types of aircraft, but, if someone said, "Oh, look, I'm a Cessna pilot. I just want to fly a jumbo jet, so I'm going to start at the Australian College of Jumbo Jet Flight in Good Weather, and not really develop the skills across a wide variety of aircraft and situations. So, we get together for the weekend, and we go to a couple of weekend courses, we buy a book, you know, 'Jumbo Jet Flying for Dummies', and learn to do it, and then we say, ‘I'm a Jumbo Jet pilot. I've got a friend who's got one, I've seen one fly, I've even touched one.’"

JONATHAN HOLMES: But Daniel Fleming insists that the behaviour of RACS and the plastic surgeons is a straightforward case of restraint of trade.

DR DANIEL FLEMING, AUSTRALASIAN COLLEGE OF COSMETIC SURGERY: Yes, this isn't an isolated incident, Jonathan, it's been going on for many years. And we have had meetings with the ACCC, because we believe that this is in breach of the Trade Practices Act. We are confident that the ACCC will investigate the Royal Australasian College of Surgeons and the Australian Society of Plastic Surgeons, to prevent these kind of breaches occurring.

DR SIMON ROSENBAUM: If I would have to say in one word what is it about - it's about money, it's about control. It's not about standards.

JONATHAN HOLMES: But, in this expensive business, money is never far from anyone's mind, whether they're doctors or patients.

In the middle of a tummy tuck operation, Dr Rosenbaum began inserting permanent sutures to tighten the patient's stomach muscles.

DR SIMON ROSENBAUM (OPERATING): And she's got a tiny little pot, not bad at all, but she does need a little bit of tightening. Interestingly, the Medicare fees schedule basically says, unless you tighten the muscle, you're not going to get a Medicare rebate.

JONATHAN HOLMES: In fact, the patient will be able to claim far more than the normal Medicare rebate, because of where the surgery is taking place.

We're in a clinic part-owned by Dr Rosenbaum, above a busy crossroads in Fortitude Valley. It looks like an operating theatre. There's an anaesthetist, a scrub nurse and some impressive machinery, and Dr Rosenbaum claims it meets the standard of a licensed day surgery. Yet, he's never attempted to get it accredited.

So far as the health department's concerned, this is a doctor's room?

DR SIMON ROSENBAUM: Doctors’ rooms, yes, that's right.

ASSOC. PROF. MERRILYN WALTON, FORMER HEALTH CARE COMPLAINTS COMMISSIONER, NSW: There is accreditation of private hospitals and day procedures centres; they are governed by regulation, but when it comes to rooms, where now the majority of cosmetic surgery is done in rooms or private businesses, there are no standards or requirements.

JONATHAN HOLMES: So it’s not ...

ASSOC. PROF. MERRILYN WALTON, FORMER HEALTH CARE COMPLAINTS COMMISSIONER, NSW: Totally unregulated.

JONATHAN HOLMES: But a licensed day procedure centre counts as a hospital for Medicare purposes. That means there's a huge incentive not to register rooms like this.

DR SIMON ROSENBAUM: The interesting thing is that, if this procedure is done in the doctors’ rooms, as it's being done here, and not in a hospital, then the patient can take advantage of the Medicare Safety Net, which gives them a very healthy refund - much more than the normal Medicare refund.

JONATHAN HOLMES: Under the Safety Net rules, patients can claim back 80 per cent of their out-of-hospital medical expenses, once they go above $720 in a year.

Dr Rosenbaum's tummy tuck patients can claim perhaps $5,000 back from the taxpayer. In a registered surgical centre, with full private health insurance, they'd be lucky to get back half as much.

DR SIMON ROSENBAUM: It's a quirk in the system, and I'm not sure how much longer that quirk will remain. I think its been of enormous benefit to many, many patients who otherwise would not be able to have their procedures, so, I think it's a great thing for the patients.

JONATHAN HOLMES: In Merrilyn Walton's view, it's anything but a great thing for patients.

Do you think that things like tummy tucks should be done in an unlicensed doctor’s rooms?

ASSOC. PROF. MERRILYN WALTON, FORMER HEALTH CARE COMPLAINTS COMMISSIONER, NSW: Absolutely not. In my 25 years in this area, there's been an increasing concern that, wherever medical services are delivered, they should be accredited, and to think that, with the improvement in sedation techniques, we're getting patients having more and more invasive procedures in unlicensed rooms is, to me, a huge worry and a catastrophe waiting to happen.

JONATHAN HOLMES: Cosmetic medicine is a competitive business, and, in any business, it pays to keep costs low. But sometimes it's worth playing safe.

Dr Josef Goldbaum of Liposuction Australia has agreed to let us tape a liposuction procedure, but he's departed from his normal routine. He's arranged to do the procedure in a fully accredited day surgery, complete with a qualified anaesthetist.

DR JOSEF GOLDBAUM TO PATIENT: Take some deep breaths, deep breath. That’s the way. No, doesn’t work.

JONATHAN HOLMES: But things don't go according to plan.

DR JOSEF GOLDBAUM TO PATIENT: Now, I just want to explain something to you, OK? All right? What you're feeling is a kind of a scraping sensation, OK? That's from the little vacuum cleaner going backward and forwards, so it feels a bit funny inside, but you’ve got - you're full of anaesthetics there now.

JONATHAN HOLMES: Despite large amounts of local anaesthetic and intravenous sedation administered by the anaesthetist, the patient is in pain. Dr Goldbaum asked the anaesthetist to give her more painkillers.

DR JOSEF GOLDBAUM: You feel comfortable giving her a bit of pethidine intramuscular, or a bit of fentanyl?

ANAESTHETIST: I could give her a little fentanyl ...

DR JOSEF GOLDBAUM: What?

ANAESTHETIST: I could give her a – a small amount of fentanyl.

DR JOSEF GOLDBAUM: Yeah, give her a small amount of fentanyl.

JONATHAN HOLMES: The anaesthetist does what he's asked, but reluctantly. He doesn't usually work with Dr Goldbaum. Because the liposuction's being performed under local anaesthetic, he's not feeding oxygen into the patient's lungs. And there's clearly disagreement between him and Dr Goldbaum about how much sedation it's safe to administer.

ANAESTHETIST: What I can't do is increase the sedation to compensate for perhaps an impossible situation that local is not going to be that effective for her, because I'll find myself up the creek without a paddle if I increase the sedation from here without access to the airway.

JONATHAN HOLMES: At this point, Dr Goldbaum tells me that normally he doesn't use intravenous sedation and, therefore, has no need for an anaesthetist.

DR JOSEF GOLDBAUM: Because you can control sensations and pain using other means, other than intravenous anaesthesia. You can just use a bit of intramuscular pethidine, for example, which works quite well.

JONATHAN HOLMES: So why have you got an anaesthetist today?

DR JOSEF GOLDBAUM: Because we're on television and because – because - I don't know - because we're being filmed, I guess.

BETH WILSON, HEALTH SERVICES COMMISSIONER, VICTORIA: I just wonder why the person involved decided that there should be an anaesthetist present when you're there and not otherwise. Was he or she concerned that something might go wrong in front of the cameras? If so, something could also go wrong when the cameras weren't there.

JONATHAN HOLMES: Surveys show that, overwhelmingly, cosmetic surgery patients end up satisfied customers.

Leanne Hezlett has told us she's happy with her new breasts, and so has Donna Newport.

Even Joan Wilkinson is pleased with the results of her Malaysian getaway.

Australians who venture abroad for surgery know they're doing it at their own risk, but they may well assume that, back home, regulations control every aspect of an industry which so directly affects their health and wellbeing. But the system puts enormous faith in doctors.

DR JOANNA FLYNN, MEDICAL PRACTITIONERS BOARD OF VICTORIA: Doctors are professionals. They are expected to do the right thing.

JONATHAN HOLMES: But in these areas, where there's enormous amounts of money to be made, can we go on relying on doctors to do the right thing?

DR JOANNA FLYNN, MEDICAL PRACTITIONERS BOARD OF VICTORIA: If we can't rely, essentially, on doctors to do the right thing, then we are in deep trouble.

JONATHAN HOLMES: It's not just a matter of qualifications. After all, Julie took care to entrust herself to a qualified plastic surgeon.

I wonder if you think that the real difference is not between plastics and cosmetics but between those who are first and foremost doctors and those who are first and foremost business people.

“JULIE”: I think you may well have hit the nail right on the head, Jonathan. I hadn't quite thought about it in those terms before, but, yes, my surgeon's very much driven by the financial gains, very savvy to publicity, television exposure, radio exposure, very conscious about the whole marketing side of things.

JONATHAN HOLMES: When surgery becomes part of the beauty business, patients become customers. Customers get to choose what they buy, but buyers should always beware.