The Sydney cosmetic injectors look the part: social media photos show them mid-procedure, wearing scrubs, clinical tool in hand.
But behind the camera, they are suspected of being part of a growing number of beauticians posing as medical practitioners, delivering potentially dangerous anti-wrinkle, filler and fat-dissolving injections in unauthorised premises around Australia.
The New South Wales Health Care Complaints Commission has confirmed that at least two are the subject of investigations into allegations they are providing cosmetic injections without the qualifications to do so – while advertising their services online. Their names have not been made public.
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When, in an unrelated case, three women were hospitalised – one in intensive care – with suspected botulism after at-home anti-wrinkle treatments in the Sydney suburb of Guildford in January, the message from NSW Health was swift: using unregistered practitioners for cosmetic injections comes with serious, and in rare cases potentially fatal, risks.
The HCCC issued a public warning, naming a woman, Norsafiza Binti Zakaria, who it alleged had been “illegally administering botulinum toxin (Botox) and other injectable substances without medical supervision”. She had been advertising her services via WhatsApp and, in January, went to a Sydney home where she injected at least three people with substances she claimed were botulinum toxin, the commission alleged.
On 30 January, the HCCC made an eight-week interim order “to protect public health” prohibiting Zakaria, as a non-registered practitioner, from providing or marketing any health service, including cosmetic procedures, in NSW and Victoria, while it investigated the allegations. Guardian Australia understands that investigation is ongoing.
As popular as botulinum toxin – the active ingredient in the Therapeutic Goods Administration-listed anti-wrinkle treatments known by a range of brands including Botox, Dysport, Xeomin, Letybo and Nuceiva – has become, its use remains tightly regulated by the TGA, the Australian Health Practitioner Regulation Agency and state departments of health.
As a powerful neurotoxin, it must be administered in precise doses by trained professionals, says Dr Vivek Eranki, the chief executive of Cosmetique, which has clinics across Australia. “Overdosing can result in breathing difficulties, muscle paralysis and in extreme cases, death.”
In Australia, most cosmetic injectables are schedule four medicines and must be prescribed by a medical practitioner, dentist or nurse practitioner and administered by authorised practitioners – usually doctors, specially trained nurses and dentists.
Overall, the regulated framework works “very, very well”, says Dr John Flynn, a former president of the Australasian College of Cosmetic Surgery and Medicine.
The price tag of procedures – about $700 for a facial anti-wrinkle treatment in Sydney – reflects the stringency but has done nothing to dent their popularity. Australians collectively spend more than $1bn a year on non-surgical procedures, according to industry figures cited by Ahpra. Grand View Research estimated the value of Australia’s facial injectables market at $4.1bn in 2023, rising almost 20% a year from 2024 to 2030.
The majority of those procedures are successful but “there is this small cohort that operates at the fringes where most of the complications occur, and when they occur, they occur badly”, Flynn says, speaking generally.
Ahpra guidelines state that non-surgical cosmetic procedures must be performed in a “facility that is appropriate for the level of risk involved in the procedure and the risk profile of the patient. Facilities must be appropriately staffed and equipped to manage possible complications and emergencies”.
The TGA advises that a “legal requirement is for cosmetic injection clinics to be licensed” – and that “illegal procedures often take place in … beauty clinics, residential homes and hotel rooms”.
Yet, says Eranki, “people are drawn to home-based operators, thinking they are cheap and convenient”.
Ever since Botox was TGA-listed in 1999, it has been imitated, undercut, sold and administered illegally. The motivation, some experts believe, is usually financial.
“This is not something that has suddenly sprung up recently here,” Flynn says of unregistered products and unqualified back yard providers working from unlicensed premises.
What has changed is fast, easy access to both the products and their market via social media.
Unregistered products, including Hyamax and Botulux, are not hard to come by online. Guardian Australia found multiple instances of attempts to sell products from overseas directly to Instagram users.
In 2023-24 the TGA received more than 99 referrals from Australian Border Force after it intercepted cosmetic injectables being sent into Australia. A spokesperson said disrupting the unlawful importation of unapproved and high-risk medicines was a “priority” for the agency but often their origin was unknown.
Where schedule four medicines are made and how they are stored counts, according to Dr Lily Vrtik, the president of the Australasian Society of Aesthetic Plastic Surgeons. “You could get anything in an unregulated product, a different dose, a mix of medications or even unprocessed medications that has not removed the non-therapeutic or the harmful component.”
The number of complaints to the HCCC doubled in 2023-24 compared with the previous year, with 21 reports about “cosmetic therapists” – non-registered practitioners.
The commission has issued four serious public health warnings about the provision of cosmetic services in the past 10 months after a rise in complaints about non-registered practitioners, a spokesperson said.
The HCCC believes cases are underreported and some customers have no idea they are in the hands of unauthorised practitioners; it is not uncommon to find falsified qualifications on display in treatment rooms. To confirm whether an injector is registered, its advice is to always check the name of a practitioner on Ahpra’s database before receiving treatment.
Since 5 September 2022 Ahpra has investigated 283 reports about non-surgical cosmetic treatments, with 18 resulting in regulatory action. More than 1,400 calls were made to its cosmetic surgery hotline – set up to report unsafe practices after an independent review into the cosmetic sector in 2022 – in the same period.
“This has become viewed as a beauty therapy-type treatment, where, in fact, it’s a medical process,” Flynn says. “Just the physical act of penetration of the skin and the installation of a biological product of some sort is very clearly, by any definition, a medical practice.”
A Sydney registered nurse and authorised cosmetic injector, Adam (not his real name), says he knows of two unauthorised injectors who advertise cosmetic injections via WhatsApp, Snapchat and TikTok. He claims that both have injected clients who later came to Adam asking for help to fix “botched” procedures.
“[They’re] masquerading as a medical practitioner, injecting filler in buttocks, face, threads, Botox, fat dissolvers, everything,” Adam claims about one.
“I would never inject someone’s buttocks,” he says, detailing the potentially fatal risk of pulmonary embolism. “Even with my years of training, I would never – there are so many vessels and arteries there.”
He says one injector charges $350 for lip fillers – barely half the market rate in authorised premises – and claims the individual has a “huge client base”.
Despite heightened scrutiny of the cosmetic sector, the problem of unregistered “back yard Botox” is getting worse, Adam says, as the cost of living intersects with the rising availability of cheap products online. He fears those responsible will “go underground” to avoid investigation.
“There are so many of these cowboys,” he says, “and they do whatever they want.”
