In the world of cosmetic surgery, image is everything and social media drives business.

Australians are lapping it up, spending more than $1 billion a year on body-altering procedures as we strive to zap away the fat and look younger.

The glamorous before-and-after posts, and tales of successful surgeries spruiked by influencers and celebrity doctors to their many followers have become glossy appeals to vanity.

For most patients, Instagram and TikTok posts and rave reviews from happy patients are the easiest way to judge a cosmetic surgeon’s abilities, which can range from posts promoting their Kim Kardashian or Beyonce-style Brazilian butt lifts (BBL), svelte tummy tucks, breast enhancements and facelifts.

But a joint Sydney Morning Herald, Age and 60 Minutes investigation has laid bare the dark underbelly of the cosmetic surgery business, where patients are left unprotected by a system that allows risks to be downplayed, profit to be put before patient safety, and laws that allow doctors with minimal surgical training to call themselves cosmetic surgeons – some after undertaking courses in facelifts and tummy tucks over a weekend.

When things go wrong, the truth is buried by heavy-handed legal tactics such as sending unhappy patients threatening legal letters, writs or gag orders in return for refunds, making it difficult for prospective customers to know what’s really going on and for affected patients to get proper recompense.

This is a world where influencers are given free or discounted procedures in return for endorsements of their surgeon or clinic, often without disclosing their secret arrangements. If they’re botched, there are contracts that prevent them from speaking up.

Dozens of patients say they were lured by before-and-after images on social media before their surgery ended in disfigurement, deformity and sometimes physical and mental pain.

Social media plays a key role in the promotion of cosmetic surgery.

Social media plays a key role in the promotion of cosmetic surgery.

Whistleblowers allege unethical, unprofessional and dangerous work practices including potentially illegal surgeries in commercial offices and conditions that “resemble an abattoir”. Medical experts have described some scenes as “barbaric” and “worse than the Wild West”.

Experts say Instagram and TikTok act as unregulated shopfronts for the cosmetic surgery industry, using influencers to lure the next batch of high-paying customers.

It is the latest scandal to hit the industry after an expose into the clinics of Dr Daniel Lanzer uncovered safety and hygiene issues and doctors dancing and laughing while thrusting long stainless-steel cannulas into an unconscious male patient. Worst of all: a culture of never admitting when things go wrong.

That expose triggered a series of regulatory inquiries and most of Lanzer’s associates had conditions imposed on their medical registration. But, six months on, the inquiries continue and the body count of unhappy patients mounts.

Now a fresh investigation has uncovered a litany of troubling practices across the country’s biggest cosmetic procedures group, Cosmos Clinics, founded by Dr Joseph Ajaka, which has clinics and day hospitals in five states. Accusations range from breaches of social media guidelines, botched outcomes and poor aftercare.

Ajaka took action in the NSW Supreme Court to obtain a copy of this investigation, to then stop it from being published. On Wednesday, the publishers successfully overturned the decision in the Court of Appeal. And on Thursday fresh action was quashed in the Supreme Court.

Keisha Amoah is one of several patients who had a markedly different experience from the public image Cosmos Clinic presents online. She had liposuction and a BBL in April 2021 at Cosmos Clinic in Hawthorn, Melbourne.

Keisha Amoah made a desperate triple-zero call after her procedure.

Keisha Amoah made a desperate triple-zero call after her procedure.

She says she was drawn in by the impressive before-and-after posts on Cosmos’ Instagram pages and by influencers making positive comments about their BBLs.

She booked in and then it all went wrong.

When she woke up from surgery she knew something wasn’t right and started screaming for help. She says she was given ketamine and the opioid fentanyl by her doctor to try to help calm her down.

Face down and immobilised in the recovery room, she was left to call an ambulance.

“Please help me, I can’t die, I’ve got three kids,” she wailed when staff finally gave in to her screams after five hours and handed her a phone so she could call an ambulance. “I’ve just had a procedure. There could be something seriously wrong. I really need to get to a hospital,” she told the emergency ambulance operator in a recorded message obtained by Nine.

Hospital records show she received multiple lacerations to her liver and she was bleeding internally for hours.

Dr Reza Ahmadi (left), who operated on Keisha Ahmoa, is pictured with Cosmos founder Dr Joseph Ajaka.

Dr Reza Ahmadi (left), who operated on Keisha Ahmoa, is pictured with Cosmos founder Dr Joseph Ajaka.

The doctor who operated on her was Dr Reza Ahmadi, a GP, who branched out into cosmetic surgery a few years ago and in October 2018, shortly before joining Cosmos, was on social media with two plastic surgeons, hashtagging facelifting and holding a certificate from the European College of Aesthetic Medicine & Surgery (ECAMS), an organisation that offers short online and face-to-face courses in cosmetic surgery. Some courses in facelifts take 15 hours.

Amoah, 26, was in pain for months, unable to pick up her young children. She had revision surgery to fix up the mess in December.

Plastic surgeon Mark Ashton, a professor of surgery at the University of Melbourne, said Amoah could have died if she hadn’t called an ambulance.

“With Keisha, what happened was he went too deep because he was unaware as to where that cannula was positioned and he started lipo-sucking Keisha’s liver … It’s worse than the Wild West. The Wild West, at least you knew you were going into an environment which was dangerous.”

Days after the surgery, on May 13, 2021, Amoah and her mother Anne rang Cosmos head office in Sydney to give a detailed account of what happened, including poor aftercare that resulted in another visit to the hospital.

Professor Mark Ashton is an expert plastic surgeon who is doing restorative work on cosmetic surgery victims.

Professor Mark Ashton is an expert plastic surgeon who is doing restorative work on cosmetic surgery victims. Credit:Chris Hopkins

“You’re only seeing the best of the best on their Instagram pages; you’re not seeing the women with scar tissue, botched surgeries that have to keep going back to get things fixed,” Amoah says.

In the eight months that followed, Reza continued to operate out of the Melbourne practice, performing surgeries on many patients including Shanade Mulelly, who says she has uneven buttocks and shooting pains down her leg after an unsatisfactory BBL and liposuction procedure.

When Mulelly complained to Cosmos head office, she says she was offered a small payment in return for signing a non-disclosure agreement (NDA), which she declined.

“The NDA basically meant that I couldn’t speak about them in any way moving forwards and they weren’t admitting that anything had been done wrong,” she said.

She lodged a complaint with national watchdog the Australian Health Practitioner Regulation Agency (AHPRA). She believes the regulators need to do their job.

“I would like AHPRA … to ensure that any person who decides to make this type of decision has the right information to help them before and after the purchase, and there is a support mechanism in place to ensure that if they need to get a refund, you don’t have to sign an NDA.”

Taylor S is another Cosmos patient in pain after a fat transfer and BBL with Reza. After the surgery, she was left with an egg-shaped rock in her right buttock that makes it hard to sit down.

Taylor S says Cosmos’ social media content led her to believe they were the best of the best, before suffering internal injuries during surgery.

Taylor S says Cosmos’ social media content led her to believe they were the best of the best, before suffering internal injuries during surgery. Credit:Chris Hopkins

“Ultimately, if it wasn’t for their social media, I wouldn’t have chosen that cosmetic surgeon,” she says.

Taylor says the before-and-after images of BBLs, and the fact they promoted doing more than 4000 of them, made her believe Cosmos was the best of the best.

When she called Cosmos’ head office in Sydney late last year, she says she got the runaround. “How can you not follow up a customer who’s in pain? I hadn’t asked for any money back, I just said, ‘I’m in pain and I just want it dealt with.’ That’s all.”

She gave up and saw a plastic surgeon who told her he could remove the lump but it would leave a hole in her buttock and he couldn’t guarantee it would relieve the pain.

“I knew there were risks involved but I didn’t know there was a potential for lifelong pain or even a hard rock to be in my cheek,” she says.

“What’s happened to me has literally destroyed my life, not just emotionally but in every single aspect of my life.”

Rebecca, Cosmos patient

There are other unhappy patients at Cosmos who were tempted by social media.

Rebecca, who asked to use this name for privacy reasons, had liposuction and a BBL at a Cosmos Clinic in NSW in July 2020. The 28-year-old community nurse hoped the surgery would boost her confidence and appearance but it upended her life instead.

“It looks like someone put a piece of fake plastic on my abdomen … like rolled out Play-Doh in the shape of a snake, bulging from one side of my abdomen to the other,” she says.

Rebecca had cosmetic surgery at a Cosmos clinic.

Rebecca had cosmetic surgery at a Cosmos clinic.

Ever since the surgery, her suffering is constant and unbearable.

“I’m in pain 24/7,” she says. “My abdomen feels like there are pins all the time pricking me across my entire abdomen. What’s happened to me has literally destroyed my life, not just emotionally but in every single aspect of my life.”

It has also left her suffering from anxiety and depression.

“I’d have panic attacks and just wake up very flustered, very aggravated and I would feel like I couldn’t breathe … like someone was choking me. I’d wake up and I would be wet. So I’d get up, I’d look, I’d check, I would think it was all in my head, so I’d have to physically touch the clothes to be like, ‘Is it all in my head or am I actually soaking wet?’ ”

She had revision surgery at Cosmos but it didn’t work. She asked for compensation to pay for a plastic surgeon to fix her abdomen. She was offered $4400 and no admission of liability.

Throughout her ordeal she posted on a private Instagram account about what had happened.

“I created a page where I took videos of what it was like first day home, what you wear – you had to wrap things around you because you were leaking – so I recorded all of that and then I stopped posting on my Instagram page because I received a letter from their lawyer threatening to sue me for defamation,” she said.

The letter claims she had engaged in a “campaign” against Cosmos to “extort and defame” them for financial gain.

She sought legal advice and decided to file a medical negligence case.

“I just thought … they don’t get to do that to me. They don’t get to destroy my life and think that they get away with it.”

The case continues and so does Rebecca’s trauma. “It’s destroyed my life. If it wasn’t for my family, I would be homeless. I physically cannot work full-time. It is too exhausting,” she says.

Rosie Terre says she was 23 when she tried to put up a negative Google review. It quickly disappeared.

Rosie Terre is a victim of cosmetic surgery.

Rosie Terre is a victim of cosmetic surgery. Credit:Louise Kennerley

The social media influencer, who has more than 90,000 followers, had a BBL at Cosmos in Sydney in 2018 that left her with lopsided hips and buttocks – and a second surgery she hadn’t factored in when she signed up for the procedure.

In late 2018 she wrote a negative one-star Google review and shared her experience on Instagram.

“It’s really sad because I thought these were the best of the best. But they showed me the opposite … So please be aware and think twice about a BBL because the suffering they put me through was not even close to worth it!”

When she warned her Instagram followers that she would soon tell all about her experience at Cosmos, she received a legal letter threatening defamation proceedings unless she deleted her Instagram story. The letter also threatened to go to the police. “We regard your conduct as extortionate and if necessary will refer this matter to the NSW Police for investigation,” the legal letter said.

Cosmos followed up with a writ in the Federal Court of Australia, which it discontinued last September.

Terre stopped posting about Cosmos but says there is no doubt the legal threats frighten people. “People are scared. They threaten people … They have so much money.”

She said it’s embarrassing to admit to a botched BBL but speaking up is necessary. “If I can help one person, I’m happy to go through what I did.”

There is also evidence Cosmos uses influencers to promote its clinics in return for discounted procedures.

One influencer contract seen by this masthead and 60 Minutes includes thousands of dollars discounted from the cost of a procedure in return for the influencer posting content within three weeks of treatment. The contract includes an instruction to post a minimum of three tagged Instagram stories. “Tag @cosmosclinic along with the doctor/nurse in charge of your treatment … the content should adopt a friendly, conversational tone.”

If things go wrong, a non-disparagement clause in the contract gags them from speaking up, “expressly or implied”.

In this case, the influencer was left in chronic pain. When they complained and asked for compensation, Cosmos offered a refund with strings attached: an NDA with no admission of liability and a non-disparagement clause.

It didn’t stop Cosmos from continuing to use the influencer’s photos on its website and there was no mention of the complications or persistent pain.

Margaret Faux, a lawyer and health regulation expert, believes the practice of paying influencers or giving them discounted or free surgery to promote the practice should be criminalised.

“Social media is a huge factor in the cosmetic industry. There are a lot of issues around body image, body dissatisfaction, influencers … but this is so serious, so corrupt and immoral and dangerous that I actually think we should be looking at this through a criminal justice lens,” she said.

Social media experts Maddison Johnstone and Michael Fraser have been investigating social media use in the cosmetic surgery industry.

Social media experts Maddison Johnstone and Michael Fraser have been investigating social media use in the cosmetic surgery industry.
Credit:Paul Harris

Social media experts Maddison Johnstone and Michael Fraser have been examining 100 cosmetic surgery operators. They say Cosmos was already popular and was able to expand its reach when Lanzer and associates removed themselves from Instagram after the expose.

The pair have developed software that captures everything posted on the Instagram and TikTok accounts of Australia’s leading cosmetic surgeons.

This is critical because a lot of social media disappears after 24 hours, making it easier to upload controversial posts undetected by the regulators.

“They use Instagram stories quite frequently and also post in their stories shared posts from the patients. So if a patient says, ‘I’m so happy doc. Thank you so much. You’re the best.’ They’ll frequently, or they have in the past, shared those testimonials – which is in breach of the guidelines,” Johnstone said.

A social media post from Cosmos Clinics.

A social media post from Cosmos Clinics.

Under the national law overseen by AHPRA, it is a breach of the guidelines to use testimonials or purported testimonials about the service or business. This is currently under review.

Johnstone and Fraser believe cosmetic surgeons are attempting to bypass this law by sharing videos or photos of patients happy with their results.

In a social media post captured by Johnstone and Fraser’s software, Cosmos founder Dr Joseph Ajaka is not looking at his patient as he talks to a camera and spruiks Vaser liposuction, which involves the use of a heated tip, while performing Vaser lipo on a patient.

“While he’s talking to the camera, he’s shoving a long, thin instrument that is about 18 inches long, and about 3 millimetres wide – let’s call it a javelin – backwards and forwards into the abdomen, and he’s got no idea where the tip of that is at all,” plastic surgeon Mark Ashton says. “This is dangerous because if you don’t know where the tip of the cannula is, the cannula can easily be in the wrong place … What that means is you can then perforate the liver or the spleen or the kidneys.”

In a 2018 video Ajaka is operating on a patient without wearing a mask. In another, he marks up a patient in a theatre while someone plays the piano.

“It is all designed to grab attention,” says Fraser.

Sexy photos of patients are posted and then shared by the Cosmos staff. It is a clever way of getting around testimonial loopholes.

Johnstone says sexy photos are becoming increasingly common across some cosmetic surgery organisations. “In some instances, it is hard to know what’s being advertised. Is it a bikini shot? Is it makeup? What’s actually happening here? There’s no procedure that’s being mentioned … These women are being used. These patients are being used in a very vulnerable sexualised way, to advertise cosmetic surgery,” she says.

“Social media is the shopfront of cosmetic surgery. Without reining in advertising conduct of providers it will be a standard practice to see sexualised images, selfies and influencers to sell cosmetic surgery.

“Advertising unrealistic outcomes, coupled with an industry that dedicates so much to image management, innocent people are being swallowed into expecting the impossible. NDAs, defamation lawsuits, legal threats and removing critical reviews leaves an uninformed consumer base.“

Reza’s social media posts had an emphasis on sexy patient photos. Sometimes he posted photos of BBLs of women he hadn’t operated on. “He posted [an image] on his Instagram page with a caption making out that it was me post-op. I was like, ‘That’s deceiving,’” Taylor S said.

Made popular by celebrity Kim Kardashian and singer Beyonce, the BBL is considered so dangerous that most trained plastic surgeons such as Ashton refuse to do them. In 2019, the British Association of Aesthetic Plastic Surgeons recommended its members not to perform BBLs after a string of deaths. They stand by that decision. Some disagree, citing research that states they are less dangerous than a tummy tuck.

The BBL is Cosmos’ signature procedure and its doctors proudly promote it by wearing “Buttman” caps. Its website boasts more than 4000 BBLs.

It’s the procedure that has earned it the most money – tens of millions of dollars – and the one it promotes most heavily.

It’s the procedure that could have cost Keisha Amoah her life – an event that Mark Ashton described as a “sentinel event” that should have resulted in Reza’s automatic suspension by Cosmos from operating.

Dr Reza Ahmadi, who was a cosmetic surgeon at Cosmos, in a social media post.

Dr Reza Ahmadi, who was a cosmetic surgeon at Cosmos, in a social media post.

“The fact that he was allowed to continue operating, putting additional patients at risk, reflects back on that organisation – as that is either focused only on money and not about patient care; or it doesn’t care about patient safety; or it is completely unaware of the risks of that procedure,” he said.

In December, Ashton reported Reza to the regulators.

Then in January Reza’s profile was quietly removed from the Cosmos website and his social media accounts disappeared.

He turned up at a no-frills bulk billing facility in Werribee, 32 kilometres south-west of Melbourne’s CBD, with plans to start offering cosmetic procedures.

In April, APHRA banned him from doing cosmetic surgery including BBLs, but allowed him to continue to practise as a GP.

A series of questions were sent to Cosmos and Ajaka, including whether or not it reported Reza to AHPRA and if so, when. It failed to respond but issued a statement.

“Cosmos has performed more than 25,000 liposuction procedures and over 4000 BBL procedures and has had no fatalities,” Ajaka said. ” That is because patient safety informs everything that we do.

“We are different from our competitors who operate low-cost/high-volume practices. We are proud of our staff-to-patient ratio. As at 2021, even though we employed twice the number of professional staff, we performed 30 per cent fewer surgeries than our largest competitor.”

In a statement Reza said he couldn’t comment because of patient confidentiality. “At all times I have acted diligently, professionally and sought to achieve the best results for my patients. I appreciate and respect the role of the Australian Health Practitioner Regulation Agency (AHPRA). I will provide any assistance necessary in order for AHPRA to carry out its functions.”

For patients like Keisha Amoah, Taylor S, Shanade Mulelly and others who he left with pain or disfigurement, the conditions on Reza are not enough.

Shanade Mulelly is a cosmetic surgery victim.

Shanade Mulelly is a cosmetic surgery victim.Credit:60 Minutes

“I just don’t feel that somebody who doesn’t do what they’ve agreed to do when they become a doctor, which is look after their patients and put their patient’s health first, should be practising at all. It’s just not fair,” Amoah says.

Cosmos recently reopened its Melbourne clinic with a new doctor who, like the others, has a standard medical degree.

In Sydney, Cosmos continues to promote itself on social media as doctors who care.

To watch the 60 Minutes program head to 9Now.

By AKDSEO