The face of a Kiwi is, by and large, a natural one. Compared to other parts of the world such as Europe, China and the US, we're a down-to-earth bunch - our age lines and imperfections are all right with us.
But as Botox and fillers become more commonplace, plastic surgeons and cosmetic doctors are warning that without changes to legislation, the bubble may be about to burst on our cosmetically unenhanced innocence.
In his debut novel, The Tipping Point, Malcolm Gladwell explains that there are certain factors, sometimes seemingly minor, that when stirred about with others at the right time and place can see a trend turn into a phenomenon - an idea, a product or practice become a new social norm.
When it comes to our faces, the Zoom era has revealed aspects of our appearance we've never really noticed before: how our mouths crease at the corners when we talk, how our foreheads furrow when we frown. Then when we leave our Zoom meeting and scroll through Instagram we're hit with the flawless dials of filler-filled influencers. It's not surprising then, that at the centre of this Zoom versus Instagram Venn diagram there grows a booming interest in cosmetic treatments in New Zealand.
For Auckland-based cosmetic doctor and censor of the New Zealand Society of Cosmetic Medicine (NZSCM), Dr Sarah Hart, she's seen the age bracket shift to a younger set of women wanting lip fillers and Botox. And in general, says the demand for injectables has quadrupled since lockdown.
But against a backdrop of no legal age limit for cosmetic injectables, a lack of public understanding about what qualifications to look for in a practitioner and a legislation "loop hole" which means anyone can import and inject dermal fillers, are we on the precipice of a dangerous new period in New Zealand's cosmetic beauty industry?
READ MORE: • The truth about weight loss surgery in New Zealand
Hart says "in an area where there's a lot of change, we need to keep things safe." And she has been privy to some concerning incidents here in New Zealand:
"We have seen members of the public import and self-inject filler," which Hart notes has more serious side-effects than Botox but is not currently classed as a prescription medicine.
"A colleague of mine had to try to help a woman who had injected a permanent filler, actually designed for use in the kidneys, into her tear trough. Once it's in there it can't come out.
"It's a highly experienced area for a trained doctor to do, let alone someone injecting a substance into their own face. That unfortunately does happen. Because you can order dermal filler off the internet. Recommended pharmaceutical companies will only supply to doctors, but there's counterfeit out there, there's all sorts of stuff that's not fit for purpose that the public can order. That's our concern."
And it's a concern that became a reality for North Shore woman Becky Zhao, 25, last week. She was left in excruciating pain and in the dark about the product that was used to attempt to slim her calves in a procedure at SU Beauty Lab on Queen St.
Zhao told the Herald she'd had Botox before with no adverse side effects but says she has "never experienced pain like this" following her treatment by a woman claiming to be a "fully qualified" nurse.
Zhao developed a fever, couldn't stand on her own and "needed my partner to help me go to the toilet". But when she contacted SU Beauty Lab staff about her reactions, asking for the serial number of the product as requested by her GP and entitled to her as part of her medical notes, Zhao says they went silent.
When the Herald contacted the owner of SU Beauty Lab they refused to talk.
Zhao says she feels deceived and angry at the total lack of concern for a client's health and urges others to do their homework before seeking beauty treatments.
According to an Auckland cosmetics nurse, who did not want to be named, Zhao's case isn't uncommon. She told the Herald she has had multiple clients come to her with tales of dodgy treatments and back street charlatans purporting medical qualifications - including rumours of a woman conducting "minor surgeries" out of her home in East Auckland and a client who underwent an unsuccessful filler treatment in a woman's garage - during Level 4 lockdown.
"There are lots of these back street operations. And because they're not qualified medical professionals there's no repercussions. So they're not scared. But they're dealing with people's lives. In the past couple of years it's become more and more common."
Hart shares that she has previously reported an unqualified acupuncturist performing medical treatments and claiming to be a doctor to the Ministry of Health (MOH).
"They were offering illegally imported botulinum toxin, dermal fillers in the nose - the highest risk location for adverse affects - and threads [a non-surgical face lift]."
But no conviction was achieved and it is believed the "acupuncturist" is still practicing. Hart says the MOH advised because a patient hadn't reported being harmed a charge couldn't be laid. And while dermal fillers remain legally available to the public, these "practitioners" technically aren't breaking any laws.
Hart explains that dermal fillers, or injectables, used for smoothing wrinkles and giving a fuller appearance to certain areas of the face, are classed as "medical devices" rather than prescription medicine.
"If something is a medical device, like a fake hip or a heart valve, these are inert objects," says Hart. "But there's a loop hole that doesn't say these are restricted for use by medical professionals like nurses or doctors, because most of the time, a lay person on the street's not going to have use for something like a heart valve.
"Internationally, dermal fillers are classified as medical devices. So New Zealand looked at that and said, we'll get into line and classify them the same. But in New Zealand we don't have protection. It opens it up because it's no longer a prescription medicine, it doesn't restrict its use. It's like this unintentional loop hole that's flicked up that means anyone can use dermal fillers, legally, and import whatever from overseas."
According to Medsafe, some dermal fillers - "for example, those containing polylactic acid " are considered medicines. However, Medsafe notes "many dermal fillers (as a medical device) do not need (under the requirements of the Medicines Act) to be administered by a medical practitioner or trained health practitioner".
Hart is working hard to change industry legislation and MedSafe has confirmed to the Herald that "new therapeutic products legislation is currently under consideration and access to therapeutic products, including access to and use of medical devices will be part of that review process."
Hart, along with other cosmetic doctors and plastic surgeons, says the fear is that we begin to see what's happened in the UK here in New Zealand.
"Thankfully, it's not got to how it is in the UK," says Hart. "The UK is an absolute s*** show."
English 'roses' – a cautionary tale
Dr Katarzyna Mackenzie is one of New Zealand's few female plastic surgeons. She has worked in London with Niall Kirkpatrick, a plastic surgeon and a driving force behind changing legislation in the United Kingdom. Mackenzie has assisted Hart by putting her in touch with Kirkpatrick for advice on how to achieve better industry regulations in New Zealand.
"The UK market was worse than New Zealand," Mackenzie tells the Herald. "Anybody can do dermal fillers or Botox. So they were working really, really hard to protect the patients from rough practitioners or beauticians who would be doing these procedures in their kitchen, for example."
And while dermal fillers are under the Medsafe microscope, Mackenzie also points to the concern that there is currently no age limit on cosmetic injectables in New Zealand. Until very recently, this was also the case in the UK.
In an article for The Telegraph, Celia Wade describes standing behind a UK school girl in a queue and recalls her horrified reaction when the girl turned to reveal "not a child's face ... or even a teenager's, but an Instagram face, a Love Island face, complete with heavy 'microbladed' brows and bruised and bloated lips. A face that, by the age of 15 or 16, had already been desecrated by cosmetic surgery."
According to the Telegraph, "41,000 procedures such as lip fillers were carried out on kids in 2020 alone". But from October a ban was announced on Botox and fillers for under-18s in the UK.
In New Zealand, an untrained practitioner is known to have used filler on a 16-year-old school student.
"That boundary, that unwise treatment, is what we're concerned about. We don't believe that's in the best interest of patients either," says Hart.
Mackenzie explains that "both the physical and mental development in a child is not complete.
"If you have a 14-year-old, they should not be seeking cosmetic treatment that puts them at risk of infections, unnecessary scarring, problems with blood supply to tissue from fillers, or blindness, which is the worst-case scenario. The consequences can be quite devastating. They are rare but they are still there."
Even if a teen was to undergo cosmetic enhancements, Mackenzie says it's not a decision that's appropriate for a child to make. "Young people cannot make a decision due to their levels of maturity. But because of social media, we are seeing these Kylie Jenner packages, Kim Kardashian packages out there."
However, as Hart points out, "if, in the case of the 16-year-old Kiwi with lip fillers, they have no complaints as a patient, there's very little that can be done.
"If the patient doesn't complain, it's very difficult to do something, because of the legislation at the moment. There's nothing that prohibits cosmetic injectables on anyone under the age of 18. We would say it's unethical and inappropriate and our [NZSCM] members would not be allowed to but then there are a lot of injectors out there who aren't our members."
As Mackenzie puts it, "the new law is required to protect young people from harm. The regulation must be tightened in regards to what qualifications people need to have and what training they need to have."
New Zealand Medical Association chair, Alistair Humphrey, says it's "absolutely" a concern he holds as well. "Botox is a drug and the guidelines of the drug should be followed. And as I understand it, it should be given to adults only. To give it to what are effectively children, I believe is unethical."
Found someone to do your lips on Instagram?
Finding a cosmetics injector can be daunting, especially when it comes to advertising on social media. And looking at someone's before and after photos on Instagram without checking their actual qualifications is asking for trouble.
"All before and after photos are supposed to be of your own patients," say Hart. "But I know injectors out there who don't have a lot of experience who have used photos from others, or lifted them off the internet. You'd be wise to do some more digging.
"When they're not part of an organisation there are no ethical boundaries that, when you're a nurse or a doctor, you learn. And learn all about putting the patient first. If these unqualified people don't have these boundaries or training they can't access the support if anything goes wrong."
What to watch out for
Humphrey says, from the public's point of view, we need all the checks and balances in place.
"If I go and see a doctor as a member of the public, I want to know that they are well trained in the procedure, that they keep up to date and it goes a little bit beyond a certificate on the wall."
He says we need a system "where the public can be confident that a practitioner, a doctor, nurse or dentist - they dispense Botox these days - is skilled, keeps up to date and has had appropriate training. If they're calling themselves a specialist of any sort, and they're not, then they are in breach of best practice guidelines.
"There will be people who say, I do some forms of surgery, therefore I call myself a cosmetic surgeon. The problem with that is it's creating an impression with the general public that you are something that you are not. Most members of the public in this country, they see the word surgeon and think they're competent to do an array of surgeries. That's not necessarily true for some of these people."
Medsafe advises that if someone advertises wrongly as "having certain health practitioner qualifications" this may be considered an offence under the Health Practitioners Competence Assurance Act 2003.
If you have experienced issues following a procedure and are concerned about the work of an injector you can make a complaint to the Health and Disability Commissioner.
Cosmetic injectables check list
• Ensure it is always clear how you can contact the company carrying out your procedure.
• If you see mention of a medical product in an ad it should be accompanied by a mandatory statement about that product and its side affects. Testimonials are also in breach of medical advertisting requirements.
• If your injector is a nurse, find out who their supervising doctor is. The more closely they work together, the better.
• Before you undergo a treatment, you should be informed about the product being used, the risks and side effects and be given an aftercare instructions form.
• The above information should be included in a consent form and you should be able to access a treatment sheet which includes the name of the product, serial number, expiry date and where and how it was injected.
Why do we seek cosmetic enhancement?
These treatments should not be seen as "trivial vanities. There are huge benefits," says Hart, who while training in psychiatary picked up cosmetics alongside. "I wasn't sure it was going to be an area that stayed around but I found I could make a really positive difference to people's lives with these simple treatments. Which - it's counter-intuitive and a lot of people look at it like it's vain - but it actually changes how people respond to you. If you are grumpy and angry looking because of your frown line, people back off from you. If that changes, people treat you differently. They will be happier and more welcoming when you look happier and more welcoming."
She says "ageing can sometimes make you look a way that you don't feel inside."
"If you look in the mirror and you look tired and grumpy, it can make you feel tired and grumpy. We know that there is that feed way. Our brains take note of that.
"I've had patients make really amazing changes to their lives when they feel they're no longer at the mercy of ageing. They go on to make diet and exercise changes, socialise more. Socialising's super important for our health and all sorts of longevity studies show being socially involved with your community is really positive for longevity."