On the outskirts of Edinburgh city centre, tucked away among the capital's £1.3 billion Granton Waterfront regeneration project and overlooking the Firth of Forth, is Scotland's newest private hospital.
So new in fact, that even the city's usually in-the-know taxi drivers were surprised to discover it existed.
The Waterfront Private Hospital, which opened its doors to patients six months ago, is the brainchild of Mr Awf Quaba and his son Mr Omar Quaba, two of the country's leading experts in cosmetic plastic surgery.
The elder Mr Quaba was the first doctor in Edinburgh to perform liposuction after arriving in Scotland from London in 1987, and was also the first to do Botox injections in the city in the early 1990s before it became known as an anti-wrinkle treatment.
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Working as a consultant plastic surgeon in the NHS, Mr Quaba pioneered a revolutionary laser treatment for birthmarks as well as specialising in adult and paediatric reconstructive surgeries for lower limb trauma, congenital hand conditions and skin cancers.
In his private practice, he was one of the first medics to operate from what was initially known as Murrayfield plc - a private hospital founded in 1985 by a group of consultants borrowing loans from the Bank of Scotland.
It was subsequently taken over by Bupa, and latterly by Spire Healthcare.
For more than 30 years, Mr Quaba's work in private cosmetic surgery took place at the Spire Murrayfield, where he continues to treat a small number of more complex patients requiring overnight admission.
However, shortly before the pandemic, he was advised that his theatre availability was being cut "by 40 to 60%".
"I had the highest waiting list there, so that created a lot of problems," said Mr Quaba.
"Then, while we were negotiating with the manager, Covid struck, and for 14 months we were not doing any work there.
"Covid eased off and the new manager said they were going to lift the prices of cosmetic surgery in a way that priced out our patients."
Unhappy by the prospect of significantly less theatre time and longer waits for his patients, who would be paying more, Mr Quaba was encouraged by his son to consider setting up their own dedicated cosmetic facility.
In 2021, they began consulting with architects and planners with a view to converting an "empty shell" premises in Granton - previously earmarked for a restaurant and nightclub - into a brand new hospital.
The glass-fronted, three-floor, cylindrical building now houses scanners, two operating theatres and three beds for its day-case patients, who can undergo a variety of surgical cosmetic procedures such as facelifts, rhinoplasties ('nose jobs') and breast augmentation under general or local anaesthetic, as well as non-surgical treatments such as Botox or dermal fillers.
The Quabas' conundrum is not unusual, although few surgeons are willing to take on the red tape and financial headaches owning their own hospital.
UK-wide, the British Association of Aesthetic Plastic Surgeons (BAAPS) says cosmetic surgery has been squeezed by a growing number of self-funding patients choosing to pay for their own operations privately rather than languish on an NHS waiting list.
Private providers typically charge around £15,000 for a hip replacement, whereas the price tag for a breast augmentation - the most popular cosmetic procedure in the UK - usually ranges from £3,500 to £8000, or less than £10,000 for a 'nose job'.
While the issue was already manifesting prior to Covid, when waiting lists were already on the rise, it has been accelerated by the backlogs created when non-urgent elective work was suspended or severely curtailed.
In Scotland, the number of "self-pay" admissions to private hospitals - meaning patients are not covered by insurance - has almost doubled, from 11,000 in 2019 to a record 21,000 in 2023, according to the Private Healthcare Information Network (PHIN).
A total of 2,870 hip replacements and 1,565 knee replacements were completed privately last year in Scotland.
This comes against a backdrop which has seen the number of patients on NHS orthopaedics waiting lists soar from around 21,500 in March 2020 to 46,000 March this year, including more than 5000 patients who had been waiting more than 18 months for their surgery.
A spokeswoman for BAAPS said cosmetic plastic surgeons are being pushed out of theatre to free up time for more lucrative, non-cosmetic procedures - especially orthopaedics.
She said: "It's a bit of a hot potato.
"The reality is that the reason cosmetic plastic surgeons are finding operating availability squeezed is not really anything to do with the pandemic.
"It's more to do with the increased profit margins that orthopaedic surgery brings to the private hospitals, over and above any plastic surgery operation.
"Those operations are being given priority because they basically make more money.
"That's what BAAPS' surgeons are seeing and commenting on across the UK.
"It was a trend that was beginning before Covid and then the pandemic just exacerbated the whole thing."
There are now concerns that the situation is helping to fuel a dangerous rise in cosmetic tourism.
The BAAPS spokeswoman added: "If it becomes increasingly difficult to see someone here, and it's already incredibly expensive here by comparison, the lure of going abroad to have cosmetic surgery at a cheaper price is going to be attractive."
Research by BAAPS found that, in the three years to November 2023, there was a 94% increase in the number of people requiring hospital treatment in the UK following botched cosmetic surgery carried out abroad - the vast majority of it in Turkey.
This has included wound infections as well as life-threatening emergencies such as sepsis, where patients are admitted to intensive care.
It is estimated that correcting hundreds of complications resulting from cosmetic surgery abroad has cost the NHS more than £4.8 million since 2018.
Mr Alastair Lowrie, a plastic surgeon based in Dundee and BAAPS representative in Scotland, told The Herald that he sees roughly 10 patients a year requiring corrective surgery for procedures gone wrong, compared to "almost none" when he became a consultant in 2012.
At least 26 British citizens have died following cosmetic surgery in Turkey over the past four years, most recently 38-year-old Kaydell Brown who died on March 26 after undergoing a “Mummy MOT” – a tummy tuck, liposuction and Brazilian butt lift - in Istanbul.
On the day The Herald visited Mr Quaba at the Waterfront Private Hospital, he was preparing to examine a patient who had developed an infected implant following breast surgery abroad.
He said: "She is sensible in that she came to us, because otherwise she would be knocking on the door at A&E and they would have to treat her."
Ken Hay, Scotland chair for the Independent Healthcare Provider Network (IHPN), said there were "ebbs and flows all the time" in private hospitals and providers were mainly responding to changes in demand from patients, rather than profit margins.
Demand for cosmetic procedures were more likely to fluctuate with the economy, he added: “When times are better and there’s more demand, demand for cosmetic surgery goes up."
Mr Hay insisted that while hip replacements were "at the higher end of profitability" on an individual basis, they tended to require longer theatre time and hospital stays for patients which impacts on capacity.
"Delivering say six hip replacements in a day is much more resource intensive than delivering 10 cosmetic procedures in the same period," he said.
"It’s not quite as straightforward as looking at one individual procedure in isolation.”
Mr Hay stressed that - in his view - people were going abroad for cosmetic surgery because it is cheaper, rather than due to UK waiting lists.
“The only reason I’ve ever heard for people going abroad for surgery is cost,” he said.
How did we get here?
Cosmetic medicine has come a long way in a short time, with the past 40 years in particular associated with an explosion in availability, affordability, and acceptance that patients might wish to go under the knife to improve their appearance.
There is evidence that the practice was taking place as far back as ancient Egypt, however, with papyruses dating back to 1600BC detailing reconstructive techniques to "break the chamber of the nose" and rebuild it to create an improved profile.
By the 16th Century, surgeons in Britain were performing operations to correct disfigurements, but the first plastic surgeon in America - the birthplace for modern cosmetic medicine - is generally considered to be Virginia surgeon John Peter Mettauer, who carried out the first cleft palate operation in the New World in 1827 using instruments he had designed himself.
Roughly a century later, in 1920s Paris, French gynaecologist Charles Dujarrier attempted what is now considered to be the world's first liposuction on a young ballerina unhappy with the shape of her legs.
The somewhat crude technique involved scraping subcutaneous fat from the knees and calves with a spoon-shaped device normally used to remove tissue from the uterus.
Tragically, femoral arteries in her legs were accidentally injured, gangrene set in, and one of the dancer's legs had to be amputated - obliterating any appetite for liposuction until the 1970s.
In Britain, advances in plastic surgery were propelled by the First World War as bullets and explosive shells led to a dramatic increase in soldiers left with devastating head and facial injuries.
Major Harold Gillies, who in 1917 established a pioneering centre devoted to facial repair at Queen Mary's Hospital in Kent, is generally considered the "father of plastic surgery" in the UK.
During the 1930s and 1940s, the 'Great Four' of plastic surgery - Gillies, Archibald McIndoe, Thomas Kilner, and Arthur Mowlem - led the way in developing skin grafts to rebuild the faces to airmen burned in the war and devised new surgical techniques to rebuild shattered limbs.
In the second half of the 20th Century, doctors trained in reconstructive plastic surgery began to explore the potential of putting their expertise to innovative new uses to reverse the signs of ageing or reshape noses, faces and bodies for purely aesthetic purposes.
Contemporary cosmetic surgery was born.
In 1962, Texan housewife Tammie Jean Lindsey became the first woman in the world to have her breasts enlarged using silicone implants, while the 1970s saw the emergence of the first modern, surgical facelifts.
By 1973, the idea of cosmetic surgery was creeping into popular culture in Britain when journalist Alan Whicker visited Californian plastic surgeon Dr Kurt Wagner, famed for performing multiple cosmetic procedures on his wife, Kathy, for an episode of his Whicker's World documentary series.
Nonetheless, cosmetic surgery in the UK lagged far behind the US for decades - and even more so in Scotland.
Taboo
When Mr Quaba arrived in Edinburgh in 1987, he was surprised by what he found.
He said: "Cosmetic surgery was so taboo. I had spent six years in London and I used to go into Harley Street to help my mentors there.
"Coming to Scotland was a bit of a cultural shock when it came to private practice.
"I used to do one day each week in private practice, and I can still remember that in my first month here I saw something like four or five patients - it was nothing.
"In my first year - in 1987/88 - I did two facelifts in that whole year. One of them was on an American lady.
"In 2022, I did 100 facelifts.
"I was the first person in Edinburgh to do liposuction, in 1987, and I had to buy the machine. The hospital didn't have one.
"These things were being done in London, but it was just having the courage to do it here."
By the early 1990s, Mr Quaba was also a trailblazer for Botox - using it initially in his NHS clinics as a corrective treatment for facial twitches and asymmetry in patients suffering from Bell's palsy.
He said: "We used to get Botox from down south in a huge container, stored at minus 30°C to treat these patients, and then it was imported from Canada.
"An eye doctor had used Botox to correct squint, but then I would go to a conference in the US and suddenly everyone was using it off-label [for wrinkles].
"That's when I started to use it, with my background.
"People used to travel great distances to go and have Botox, and now you blink and it's everywhere in the UK."
Over the past 20 years, since Botox was first approved by medical regulators in the US as a treatment for wrinkles in 2002, the cosmetic sector has undergone a radical transformation.
Reality television, celebrity culture, social media influencers, and the rise of smartphone 'selfies' (and their filters) have all been cited as contributing to an explosion in demand for cosmetic procedures and the normalisation of surgery.
A surge in the number of providers entering the market has also led to increased competition.
There are signs that demand for surgical cosmetic procedures may have peaked, however - at least for now.
According to the annual audit carried out by BAAPS, the number of surgical cosmetic procedures carried out in the UK climbed from 36,482 in 2009 to a high of 51,140 in 2015.
Following a brief post-pandemic bounceback, it had declined to just under 26,000 last year.
Male cosmetic surgery peaked at 4,757 procedures in 2013, but had fallen to 1,822 last year.
The number of breast augmentation surgeries has plunged from more than 11,100 in 2013 to fewer than 5000 in 2023, with practitioners reporting that women are seeking smaller-sized implants compared to a decade ago.
Meanwhile, 'nose jobs' more than halved from 4,878 in 2013 to 1,950 last year, and face and neck-lifts have gone from a peak of 7,419 in 2015 to 1,742 last year.
Surgeries associated with slimming, such as liposuction and abdominoplasty - colloquially known as a 'tummy tuck' - have also declined: lipo from 5,551 procedures in 2015 to 2,424 last year, and 'tummy tucks' from 3,466 in 2013 to 2,830 in 2023.
Commenting on the latest statistics when they were published in April, BAAPS president Marc Pacifico blamed the "prevailing recessionary environment" for the downward trend, along with an "increasing number of individuals opting to travel abroad, particularly to destinations such as Turkey, in search of cheaper options for popular surgical procedures like liposuction and breast augmentation".
Nothing has changed the landscape of cosmetic medicine more over the past 15 years, however, than the boom in non-surgical procedures.
These range from injectables such as Botox to target fine lines and wrinkles and dermal fillers to restore volume, to microneedling, lasers, chemical peels, cutting edge facials, and injections of hyaluronic acid to hydrate and rejuvenate the skin.
Cosmetic medicine has shifted out of the hospital and onto the high street as a huge range of other healthcare practitioners - including dentists, doctors and nurses - have seized the opportunity to make money from a sector once confined to plastic surgeons.
'TikTok told me to'
Since April 2017, all independent clinics in Scotland run by a healthcare professional been required to register with regulatory body, Healthcare Improvement Scotland (HIS).
According to figures provided to the Herald by HIS, the number of independent clinics registered in Scotland - the majority of which provide some kind of cosmetic treatment - has soared from 200 in April 2017 to 503 in 2023/24.
Unaccounted for - and a source of mounting controversy - are the number of premises where non-healthcare practitioners, such as beauticians, are providing cosmetic treatments.
While not banned from doing so, non-healthcare practitioners who perform non-surgical cosmetic procedures are not currently subject to regulation by HIS.
The Scottish Government is currently considering tighter restrictions.
It is also under pressure to consider banning Botox and filler injections for under-18s, something England enforced in 2021.
Dr Nestor Demosthenous, a trustee of the British College of Aesthetic Medicine and a specialist in non-surgical facial rejuvenation, said that while half the patients who come to his Mayfield Clinic in Edinburgh are over 50 he was recently approached by two women in their 20s seeking Botox.
He refused.
He said: "When I asked them why, they both said the same thing: 'TikTok told me'.
"There's this illusion of preventative Botox which is what's driving a lot of younger people and preventative Botox, to my mind, isn't a thing.
"The way to avoid lines is really to go hard on your skincare and skin treatments.
"In your 20s, you should not be reaching for Botox."
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He stresses that there is plenty to be excited about when it comes to advances in cosmetic medicine.
His clinic recently purchased a new laser device, AviClear, which can treat acne as effectively as Roaccutane, a drug which carries risks of liver damage and suicidal ideation.
Patients using it must have their blood monitored.
Dr Demosthenous said: "Roaccutane has a very high risk profile but a high reward too, because terrible acne can destroy someone's confidence.
"Now this laser can deliver the same results without those risks. That's monumental."
As for the future of aesthetics, regenerative medicine - also known as tissue engineering - is the next frontier.
Science which has so far focused on trying to "turn back the age" of organs by harnessing the body's natural ability to heal itself is expected to make inroads into cosmetic medicine, in much the same way as facelifts evolved from post-war skin grafting.
Dr Demosthenous said: "If we can turn back the age of organs, if turn back the age of skin, if we can get them to function the way the did before - that's the realms of regenerative medicine.
"It's filtering into aesthetics at the moment.
"Things like laser treatments that help to cause controlled trauma to skin so that the skin produces more collagen, more elastin, that's partly regenerative medicine.
"Now we're seeing the introduction of things called polynucleotides, which are fragments of DNA.
"If we inject these into skin, we're now getting skin cells to produce more collagen, and we're getting them to produce collagen of the quality that they did before, so now we're properly starting to regenerate skin.
"Polynuceotides have been around in the UK for three, four years, but it's really only in the past two that they've gained more and more ground.
"If we combine that with laser treatments and microneedling, then it gets really exciting.
"Where are we going to go from here? I'm sure we're going to get to the point where we can regenerate bone to some extent."
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