How TikTok and Instagram have fuelled demand for nose jobs, butt lifts and boob implants.
Evelyn Peters woke up and realised something was wrong. She had lost sensation in her leg, which was disturbing because she had just undergone surgery on her bottom. Soon she was unable to walk. She was at a European medical clinic, far from home, terrified. "The pain was excruciating," she recalls. An infection developed and she was put on a course of antibiotics and high-powered painkillers.
Peters, whose name and personal details have been changed, had flown from her home in Manchester to the clinic for a Brazilian butt lift (BBL), a cosmetic procedure in which fat is taken from the torso and injected into the hips and bottom. The result is an exaggerated hourglass shape that has become popular in recent years, especially on social media, where women pose to show off their surgically sculpted bodies and swap tips about finding doctors.
Peters had been wanting a BBL for two years. In addition to the fat transfer, she opted for bum implants to accentuate the effects. "This was finally going to be the year," she says. "That's what I decided."
She found her surgeon on Instagram. He had hundreds of thousands of followers and a steady stream of "before and after" surgery posts and happy patients. The rave reviews in his feed were enough for her.
Peters booked her flight, paid the €8,000 ($13,000) fee and went under the knife. Then it all went wrong. The infection got so bad that it required a second surgery — which didn't fix the problem. She flew home in agony, dosed up on painkillers and bleeding through her sutures. Back in Britain she went straight to A&E, where doctors said they were "shocked" by the extent of the infection.
Peters ended up having a third surgery to remove her implants. The experience has left her depressed and in a legal fight with her original surgeon (she asked that his identity not be revealed for fear it could impact a potential financial settlement). Her lower half is permanently disfigured, with visible indents in her backside that look, she says, "absolutely disgusting", and she suffers pain that requires a steady supply of codeine.
"I've got major cavities. He cut holes in my body," she explains. "I cannot correct it, and I will not, because I'm not putting myself in a position like that again." Despite the trauma, she is thankful that she can at least walk, and has the support of her partner. She continues: "It's just a shame I wasn't able to love myself enough and that I put myself mentally through something that I thought I would never make it out of."
Peters and her "Instasurgery" experience are a cautionary tale. Social media has upended countless industries, from media to advertising and music; it's doing the same to cosmetic surgery. Once known for discretion, where doctors relied on airbrushed pamphlets, tasteful websites and word-of-mouth recommendations, the sector has come to be dominated by apps such as Instagram, TikTok and YouTube.
Getting a nose job didn't used to be something to shout about. Now, on TikTok, thousands of young people post videos of their transformations. Some clips with the "nosejobcheck" hashtag, which typically involve a time-lapse video of the days leading up to surgery and through recovery until the last bandage is removed, have been viewed more than two billion times.
On Instagram and YouTube some influencers are given free nips and tucks in exchange for endorsements of their "amaaazzziinngg" surgeon, often without disclosing their financial arrangements. In the US doctors desperate for followers strike "creator" deals with social media platforms that pay them for posting videos. To grab eyeballs, one surgeon in the US even dances with a breast implant perched on top of his head.
The social media industry finds itself accused of being two-faced. While it bends over backwards to show that it is "body positive", running campaigns to promote acceptance and pride in "normal bodies", it also facilitates a booming bazaar in cosmetic surgery.
TikTok, for example, bans plastic surgery ads in Europe and North America, as well as images that are "shocking, graphic, sadistic or gruesome". Yet a cursory search turns up countless grisly videos of liposuction, nose jobs and breast augmentation. Instagram restricts paid-for ads for weight-loss apps and cosmetic surgery to users older than 17, and specifically prohibits before and after images that "imply or attempt to generate negative self-perception".
But the policy is far from airtight. First, young people often lie about their age when setting up their accounts (the minimum age for someone to have a social media account is usually 13). Second, the restrictions for non-paid content are less stringent. So surgeons regularly post before and after images in the same way a food influencer might post a photo of their avocado toast. They're not paid ads, but they serve the same function for the hordes of people who follow those accounts.
The upshot: social media is normalising the idea that anyone can "fix" themselves through invasive and often risky medical procedures. The medical profession in some countries is occasionally a willing accomplice. A surgeon in Los Angeles explains: "Just five or six years ago hospitals were so hesitant about social media. They would drag their feet when you tried to put up a website. Now they are realising that social media is a big part of how to get well-paying patients through the door. We now have a sign in the hospital that encourages selfies."
The boom is so competitive, it generates scams. Unscrupulous doctors steal the photos of others and pass them off as their own, overselling their abilities — often with disastrous or even fatal results.
Dr Matt Schulman, a New York doctor with a large YouTube and Instagram following, says surgeons have stolen his images "half a dozen times" for their own advertisements. Several of the offenders were overseas clinics. "There's really no one policing it," says Schulman, who tries to stop the misuse of his images and is not aware of anyone suffering adverse consequences as a result of them.
Dozens of women have died after flying to clinics in Turkey, the Dominican Republic, Mexico and Colombia, where prices are cheaper and standards more lax. Joselyn Cano, an Instagram model from southern California with more than 12 million followers, died in December 2020 owing to complications from a butt lift she underwent in Colombia.
British women seeking medical treatment abroad are equally at risk of being duped. I spoke to three women who had badly botched procedures, two carried out in Spain, one in the US. In the course of negotiating financial settlements with their doctors they were forced to sign non-disclosure agreements (NDAs) that bar them from speaking about their experiences and require that they remove any negative social media posts. The NDAs ensure that the doctors in question retain feeds that are populated entirely by glowing reviews and flawless results.
In Britain a study by the Committee of Advertising Practice (CAP) and the Advertising Standards Authority (ASA)found in November that there was an "ever clearer picture" that online images and ads about cosmetic surgery pose a threat to vulnerable young people. So the CAP is introducing a ban, from May 25, on ads for cosmetic interventions that target people under the age of 18. The ban will cover ads for procedures such as breast enlargements, "tummy tucks", nose reshaping and facelifts, plus non-surgical interventions such as dermal fillers and chemical peels.
But banning paid-for ads won't necessarily stop non-paid posts that are effectively promotions. And in an online borderless world that is hard to police, it remains to be seen how effective the move will be.
Between 2010 and 2019 cosmetic surgery procedures in America surged by 36 per cent, a period that coincided with the rise of social media (Instagram was founded in 2010) and the proliferation of less invasive procedures such as face-freezing Botox injections. Although the official figures show that Britain has seen a sharp fall in procedures over the same period, according to data compiled by the British Association of Aesthetic Plastic Surgeons (BAAPS), those figures may well be misleading.
"There's an awful lot of cosmetic surgery going on that is unaudited," says Dr Mary O'Brien, the BAAPS president. A thriving market of untrained people offering non-invasive procedures exists, she says, as well as doctors who are not registered as members of the BAAPS and whose procedures don't make it into the figures.
While the pandemic initially shut down virtually all elective surgeries, doctors say that the "Zoom effect" — when looking at one's face for hours on conference calls motivates people to have surgery — is driving renewed interest. Anecdotally, patients also appear to be getting younger. Dr Dario Rochira, who has offices in London and Rome, explains: "On TikTok, you only reach 15 and 16-year-old girls. If I show you my direct messages, I'd say 80 per cent of them are, like, 'What age do you do rhinoplasty [nose surgery] from?', or 'If my parents agree, can I have a consultation?' " Rochira focuses on Instagram, which he says has more adult users.
For doctors, the stakes are high. Business is often directly correlated with the number of followers they have. Rochira (who faces no suggestion of malpractice) posts three stories a week on Instagram, sometimes using before and after images or a surgery video. "I would say that 70 to 80 per cent of my patients come from Instagram," he says. "It's very time-consuming, though. Patients want to see me, not someone else."
Chloe Rose, a London-based fashion influencer with 251,000 Instagram followers and 43,000 subscribers to her YouTube channel, got a nose job from Rochira three years ago. He recalls: "She said, 'I'm happy to pay but I would like you to consider giving me free surgery, and I can promise you I will do everything I can to promote you, in the best way I can, for ever.' " He agreed — and says the deal has paid off handsomely. "Loads of patients come from her because they follow her."
Louise Seddon, a 42-year-old small business owner and mum from Cardiff, hired Rochira for a nose job in June after finding him on Instagram. She even created a new account to document her procedure and recovery. "I wouldn't have chosen a surgeon without an Instagram account," she says. "It makes them accountable to people."
Yet one in three young people says that Instagram and its feed of "just so" photographs of beautiful people make them feel worse about their body, according to a whistleblower's dump of internal research from Facebook reported by The Wall Street Journal. In Britain, 13 per cent of suicidal British teens blamed the app for such thoughts; Instagram's own researchers have said aspects of the app create a "perfect storm", where angsty young people are bombarded with images that exacerbate their insecurities.
Peters, the BBL patient who is in her late twenties, says she is "110 per cent certain" that social media has amplified what she believes is her "body dysmorphia". Before her BBL she had had her nose and breasts enhanced. "If Instagram didn't exist, I don't think there would be as many insecurities," she says. "I know loads of girls who edit their photos to be more curvy or to be more skinny. When you see them in person, they look nothing like their photos."
She goes through periods where she deletes her account, only to reopen it months or years later. "I've never had an Instagram for more than a year," she says. "I deactivate it because I do feel the pressure of it and I need to focus on my mental health."
Two years ago Instagram banned "cosmetic surgery" filters — those where generating plumped lips and filled-in wrinkles created what came to be known as "Instagram face". It said at the time: "We want our filters to be a positive experience for people." The move was an early nod to what has become increasingly clear, especially in the wake of the Facebook whistleblower's revelations. For a certain part of the population, Instagram makes them feel bad about how they look.
The company said: "Our policies are designed to help keep our community safe on Instagram, and that includes reducing the pressure that some people can feel as a result of social media."
Instagram pointed to recent initiatives such as All Bodies Welcome Here, which encourages people to share their stories of acceptance and pride in their bodies. Among the influencers it highlighted was Kendra Austin. However, in September Austin complained in a video to followers that her exalted role as flag-bearer for bigger people was itself "dehumanising" and "disingenuous".
Similarly, TikTok claims to have taken a hard line. It has banned cosmetic surgery ads in Britain, Europe and North America, and says it prohibits accounts that violate its policies against weight loss ads, nudity and graphic content. It added: "Being true to yourself is celebrated and encouraged on TikTok. As a platform, we're focused on safeguarding our community from harmful content and behaviour while supporting an inclusive — and body-positive — environment."
Yet O'Brien, president of the BAAPS, is in no doubt about the dangers. "There is a real issue with social media and marketing of cosmetic surgery in this country," she says. "Some companies and practitioners are putting profit before patients."
A patchwork of regulations in Britain leaves gaps through which the unscrupulous can slip. In the UK, the CAP lays down strict advertising guidelines by which the General Medical Council (GMC) expects doctors to abide. The GMC offers more specific rules on cosmetic surgery marketing, but all its rules apply only to bona fide doctors. The BAAPS, Britain's top professional body for cosmetic surgeons, has a code of conduct that conforms closely with the findings of the Keogh Review, a 2013 report commissioned by the Department of Health that said ads must be legal, decent, honest and truthful. The BAAPS, however, has little power over transgressors beyond kicking them out of the association.
On top of that, the Royal College of Surgeons has created a certification scheme that enables people to check whether their prospective doctor is trained in the procedure they may be offering. And finally the ASA can investigate and sanction people suspected of misleading advertisements.
But on the other side of all those measures is a firehouse of social media posts being blasted around the world by cosmetic surgeons, non-specialists — in the US anyone with a medical licence can call themselves a plastic surgeon — or even non-surgeons. In the US in particular, doctors have been quick to see the opportunities offered by new apps. Take the case of Dr Daniel Barrett, who had a "beautiful" operating room in Beverly Hills but no clients. It was April 2020 and the pandemic had shut down his plastic surgery clinic. So he started experimenting with TikTok, which is geared towards entertainment and performance. Barrett, with 17 years of medical training under his belt (and no suggestion of malpractice), messily dissected a breast implant and posted it on TikTok. He juggled breast implants. He sang to them. He posted a gruesome cyst-removal surgery video with the caption, "Boba tea, anyone?", a reference to a popular beverage filled with marble-sized balls of tapioca.
In another video he held aloft a mammoth mass of fat and skin, freshly shorn from a patient, echoing the opening scene from The Lion King, while music from the film played in the background. In Britain such conduct wouldn't be allowed; on TikTok, though, it was a hit. In his first week on the app, Barrett gained 100,000 followers. His following has since soared to 1.8 million, coinciding with TikTok's own meteoric rise. Last year it became the world's most downloaded app and in September hit a billion monthly users. And they tend to be very young.
About 13 per cent of American parents with children under 12 said their kids used TikTok, according to Pew Research — nearly three times the 5 per cent who said their children were on Instagram. In 2019 TikTok paid a then-record $5.7 million fine for harvesting the data of underage users.
Barrett says the app now accounts for a third of his patients. "They are definitely younger and more willing to share — and actually come in and do TikToks in the office with me. It used to be that girls in Beverly Hills would get a nose job before they headed off to college, but it was a taboo subject. Now it's wide open."
In April Barrett launched, and has since closed, an account on OnlyFans, the app popular with creators charging subscribers for explicit content (last year the company toyed with banning porn, then changed its mind), so that he could show graphic surgery videos that are banned by Instagram and TikTok. "I lost my Instagram account for three months because I showed a nipple one time," he recalls. He was eventually reinstated after pleading his case, including writing a letter to Mark Zuckerberg, but says the episode "devastated" his business. He adds: "Plastic surgeons don't really fit the mould [of healthcare practitioners] — we have more creative streaks."
None was more creative than Daniel Aronov, an Australian doctor who amassed 13.4 million devotees on TikTok with a stream of gruesome surgery videos that often ended with him jiggling up a bloody mass of fat or muscle for the camera. Either that or he'd do a spot of dad dancing. In October, however, an investigation by several Australian media organisations alleged potential safety and hygiene breaches at the clinic he shared with other doctors. The reports included a video shared internally that showed physicians dancing to the Dolly Parton song Jolene while they performed liposuction on an unconscious patient.
A month after the reports, Australia's medical regulator banned Aronov from performing cosmetic surgery. Another surgeon prominent on social media, with whom Aronov had shared a clinic and was the primary focus of the exposé, agreed to stop practising medicine in Australia. Neither responded to requests for comment.
Despite such controversies, some doctors argue that the industry's move out of the shadows is, largely, a good thing. Schulman says his most popular posts are videos of actual procedures, which typically involve flaps of skin, vats of fat and lots of cutting and sewing. Some doctors use Instagram TV as their own surgery channel to educate people on what is involved in different procedures.
The upshot, they say, is that many patients have a far deeper understanding of what they are walking into. Seddon, who had her nose done in June, explains: "The good thing about Instagram and social media is that you can find other patients and learn about their experiences." Once she booked her appointment, she hopped on to YouTube to find videos that left no doubt about what she had just agreed to. "I saw one where the surgeon broke the patient's nose," she says. "It was brutal — but it didn't put me off."
Written by: Danny Forston
© The Times of London