Filling the gap: Regulating the non-surgical aesthetics industry

In September last year, Alice Webb died at Gloucestershire Royal Hospital after falling ill. The 33-year-old, a mother of five, had recently undergone a non-surgical ‘liquid’ Brazilian butt-lift (BBL). 

The most commonly thought-of BBL involves the surgical removal of fat from other parts of the body or uses silicone-filled implants, and can cost between £3,000 and £8,000. The NHS describes it as “a big decision” with “risks”, while the “results cannot be guaranteed”.  

A liquid BBL, the kind Alice received, is a non-surgical procedure often performed under a local anaesthetic with large quantities of injected dermal filler, typically hyaluronic acid. It is not classed as a medicine and therefore does not need to be prescribed and is readily available online. It is a cheaper way to achieve the desired larger, shaped buttocks and generally doesn’t last as long as a surgical BBL as the filler dissolves within a few years. 

While liquid BBLs don’t carry the risk of surgery, the NHS and many in the cosmetic industry strongly warn against receiving the treatment. The reasons are simple. The non-surgical market is unregulated, and the regulatory gap permits anyone without medical training to administer such treatments, whilst registered healthcare professionals, who also carry out the work, in Scotland are regulated by Healthcare Improvement Scotland (HIS). This two-tier system has led to calls for standardised training and mandatory qualifications from within the cosmetics industry. 

In April last year, Edinburgh City Council issued a call “as a matter of urgency” after it received information that procedures were due to take place in the capital. Companies had been identified advertising the treatment on social media at private locations, which would not be disclosed until a later date – done to avoid scrutiny from local authorities and Scotland’s Care Inspectorate.  

And there’s a reason why many of these unregulated practitioners want to operate discreetly. While many take place in clinic rooms, there have been growing reports in the last few years of procedures occurring in hotel rooms and office blocks. Many industry figures have described these practices as “the wild west”. 

According to figures from the Rare Group, a healthcare data and research company, 7.7 million people had an aesthetic treatment in the UK in 2023 – 11 per cent of the population – while 13.9 million people said they were considering having a treatment in 2024. These treatments can range from waxing and laser hair removal to dermal filler for the lips and buttocks. 

Alice’s death is believed to be the first caused by the procedure in the UK. Her partner Dane Knight told ITV News a month after her tragic passing that he believes she would not have undergone the procedure had she been aware of the “full risks” to her health. 

Dr Michael Mrozinski, a Scottish doctor with over half a million followers on TikTok and Instagram, and used to doing some aesthetics work, is a strong advocate for better regulation. He tells Holyrood that since 2015 the unregulated market has “exploded”.  

“I couldn’t believe that people could have no training, do a weekend course, be a bus driver, cabin crew, a factory worker – and these are not jobs to put down – but they’re not people who should be putting a needle into your face after a course lasting a few days. 

“They think after doing these short courses that they know everything, they go out and start getting clients, practicing on people, thinking they’re experts already. But unfortunately you can’t just skip the experience. You won’t know what a complication is until you’ve had experience dealing with them and their inability to spot a problem early can lead to people being disfigured or their health being really badly affected.

“If someone injects filler into the artery of the lip it can get stuck and block it off; if that’s not seen to within 24 hours you can end up with necrosis. People have lost chunks of their nose and lips from this.” 

SaveFace, a UK Government-approved aesthetic treatment register, says around 90 per cent of people that make reports find their practitioner on social media, and those people are getting younger every year. 

There is a clear demand for treatment that is fuelling the unregulated market. Last year’s Girlguiding Girls’ Attitude Survey reported that over half of girls aged 11-21 said they wished to look like social media filters. According to a study by the University of Edinburgh in 2022, filters have been found to “drive consumers towards cosmetic procedures in the hope of bringing the digitally-enhanced versions of themselves to life”. The study found that all 16 participants, aged 18-30, looked to Instagram influencers for information about cosmetic procedures and suggested that platforms like Instagram are impacting people’s perception of body image.  

Mrozinski, who has been calling out social media influencers for selling their treatments to their followers, says these people “are using their leverage from social media and people trust them because of their celebrity”. 

“It absolutely crazy. The public is really naive to this and with some of them offering really cheap treatments people will do it.  

“It doesn’t take an expert to work out if you’ve got the overheads and expense of running a regulated clinic you need to charge more, and they can’t compete on a cost basis with people who are doing it out of a back room somewhere. It’s a race to the bottom.” 

Lesley Blair, chief executive of the British Association of Beauty Therapy and Cosmetology (BABTAC), describes the influence of social media on the industry as “a double-edged sword”. 
“We are seeing an increasing number of influencers getting treatments done. This is a lucrative industry, and we’re seeing people setting up on TikTok and Instagram, people that have normal nine-to-five jobs, doing some of this work at the weekend. 

“And whilst I really support people pivoting into our industry, which is heavily female-led and 80 per cent of the businesses are owned by women, we are advocating heavily for people to do the proper training.  

“That’s where social media is a downside, because people see it as very easy to access, particularly if you don’t have the right training. We need to be using it to get our message across and inform consumers about seeking out qualified practitioners.” 

She is arguing for modular training for non-surgical cosmetic procedures that are mapped against the National Occupation standards, which are “benchmarked by the government and the industry”. 

SaveFace says since 2022 it has seen “an alarming increase” in the number of patient-reported complaints relating to non-surgical breast augmentation and BBLs involving high volumes of hyaluronic acid dermal fillers. Over 18 months, it received 639 complaints about BBLs and 29 relating to breast augmentations. It describes the severity of complications caused by these procedures as “alarming”. 

It says that 50 per cent of the cases reported have resulted in severe and life-threatening complications such as sepsis, infections and abscesses that required hospital admission and often surgical intervention. The remainder of the complainants reported unsightly outcomes such as severe pain, hard lumps, and filler migration. 

While the industry grows, the NHS is often left to pick up the tab for botched procedures. 
The British Association of Aesthetic Plastic Surgery estimates that a botched liquid BBL costs the NHS an average of £15,000. As many as 98 per cent of the patients that were included in Save Face’s data have been treated by the NHS as a result of the non-surgical cosmetics they received.  

Mrozinski describes some of the images and videos he has been sent from “backstreet clinics” since talking about the issue online as “frightening”, and says the industry is like “the Wild West”. 

“There are thousands of places in Scotland offering treatments and we simply don’t know what they are doing, we don’t know what they are using, who’s doing it, what products they’re using and where they are getting them from, what the hygiene is like – all the stuff you would have to do if you were registering a clinic with HIS. We really need to be asking things like how people are getting their hands on prescribed medicines like Botox. 

“Don’t get me wrong, there’s probably clinics out there that are doing a decent job, but it has to be standardised. If you’re injecting people you need to be the same standard as the doctors or the nurses.” 

A survey by the Medical and Dental Defence Union of Scotland (MDDUS) found that one in three doctors have treated patients for injuries resulting from unregulated cosmetic procedures, with patients as young as 16 years old. 

This has led to Scotland being described as “the worst in Europe” for injectable fillers. Unlike the rest of the UK, in Scotland 16-year-olds are permitted to receive injectable filler treatments, while the age in the rest of the UK was increased to 18 in 2021.  

The Scottish Government’s public consultation on regulating non-surgical cosmetic procedures closed last month.  

In December, public health minister Jenni Minto said the government is working to understand how to address the gaps that mean anyone without training can perform these procedures and acknowledged people’s “traumatic” experiences. 

She said: “While there are many reputable practitioners, we have seen an increase in people who have experienced complications from procedures that have gone wrong. 

“I’ve heard moving testimony about negative consequences.” 

The government is proposing a tiered regulatory system that defines who can carry out a specific treatment. For example, Group 1 will contain procedures considered a low-level risk and can be safely carried out by a trained practitioner who is not a healthcare professional. Higher-risk Group 2 treatments would require non-healthcare professionals to obtain a licence from their local authority and take place in an independent clinic, or other healthcare setting regulated by HIS, while Group 3 should only be carried out by healthcare professionals in a HIS-regulated premises. 

Mrozinski is critical of the Scottish Government. It’s a problem we’ve known about for years and “they’ve been digging their heals in”, he says.  

“We’ve been so slow to react to this, and the problem now is, because there’s so many people doing injections, holding them accountable to HIS will cause a riot, even though they should have been doing it in the first place. Someone has already died in England, and the same will happen in Scotland if it we don’t stop this soon.” 

Stuart McMillan, one of the MSPs in the Scottish Parliament who is leading the charge for regulation of the industry over the last few years, believes Scotland needs to act swiftly to increase the age minimum age of a person that can receive treatment to 18. 

“That’s one of the first quick fixes that can be done right now and bring us level with the rest of the UK,” he says. 

“Another is to bring the aesthetics industry in line with the same licensing regulations that tattoos and piercings are under. Immediately that would help make it harder for people at the bottom end to operate – that’s a quick safeguard. 

“There’s of course much more depth that is required, and that’s where the consultation will work to help the people who are in that middle end, not medically qualified, who are worried about their business as we regulate this industry but are willing to undergo the correct training.” 

McMillan suggests regulations could take some time due to parts of the issue being reserved for the UK Government. For example, regulations over medicines and medical devices are reserved, meaning the definition of things like fillers sits out with the powers at Holyrood.  

While the Scottish Government has powers to regulate who can perform non-surgical cosmetic procedures, some reserved issues could “slow down regulations”, McMillan suggests. 

He says utilising Section 104 of the Scotland Act (1998), which ensures that new laws passed at Holyrood which impact reserved areas work within the UK legal framework, could be used in this instance, pointing out it has been used for the Domestic Abuse (Scotland) Act 2018 and the Scottish Biometrics Commissioner Act 2020. This would require both houses at Westminster to vote in favour and McMillan fears it could take up to 18 months.

“If there are things that the government can do within the devolved area that don’t impinge on anything that is reserved then I would encourage it to do that as soon as possible. 

“The Section 104 won’t happen overnight, but anything that is reserved that the Scottish Government identifies from going through the responses to the consultation, it needs to start engaging with the UK Government immediately.”