Campaigners and healthcare professionals have warned that lives are being put at risk by a growing number of unregulated practitioners performing everything from Botox injections to 'butt lift' procedures without any medical training.
An investigation by The Herald has heard of an alarming string of injuries and near misses, including 15 women hospitalised with life-threatening allergic reactions after being injected with counterfeit Botox from China which turned out to be beef gelatine.
There are also cases of surgical procedures being carried out in hair salons, high-risk liposuction procedures performed by people straight out of retail jobs, and patients requiring emergency care from plastic surgeons due to "raging infections" after undergoing potentially dangerous thread-lift facials on the high street.
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"It is a UK-wide issue but in Scotland we are the laughing stock of Europe," said Dr Nestor Demosthenous, a trustee of the British College of Aesthetic Medicine and specialist in non-surgical facial rejuvenation who set up his practice in Edinburgh, the Mayfield Clinic, in 2016.
He questioned why Scotland has not yet tightened regulations nor followed England's example of banning under-18s from getting Botox and fillers.
Dr Demosthenous said: "If I were to see a patient outside of a [Healthcare Improvement Scotland]-regulated clinic and treated them in premises not registered with the health board, I - as a doctor - would be taken to the procurator fiscal.
"If a plumber were to inject a 16-year-old girl with filler in the back of a van, completely legal. It is absolutely ridiculous."
The Scottish Government is currently weighing up what to do about the rapid expansion of the cosmetic sector, which has been fuelled by a proliferation of new non-surgical treatments.
In 2016, it began the rollout of what was originally envisioned as a three-step overhaul of the industry.
Under the first stage, healthcare practitioners such as doctors, dentists, nurses, and midwives were given until April 2017 to register independent clinics with the regulator, Healthcare Improvement Scotland (HIS).
Figures obtained by The Herald show that the number of HIS-regulated clinics has gone from 200 in April 2017 to 503 in 2023/24.
Not all, but a majority, of these premises are performing some kind of cosmetic procedure - from Botox to teeth whitening - but these clinics are subject to inspections, and owners must pay annual regulation fees of £1,670 plus £3,500 to register.
The second stage anticipated that regulation would be extended to encompass people such as clinical scientists using laser treatments, and finally to non-healthcare practitioners such as beauticians.
Critics have argued that the framework has proceeded back-to-front by "regulating the regulated" since doctors, nurses and dentists can already be struck off for malpractice, while individuals with potentially little training or qualifications have been free to operate without any safeguards and none of the regulatory fees.
'Grave Concerns'
Unlike in Europe or North America, in the UK there is nothing to stop individuals with non-medical backgrounds from carrying out cosmetic procedures such as Botox or dermal filler injections assuming they have completed relevant training courses.
Level 6 and Level 7 qualifications in Botox - which cost around £9000 in total - can be completed in as little as two weekends.
As a prescription drug, however, Botox should not be available to anyone without prescriber credentials - namely doctors, dentists, nurse prescribers or prescribing pharmacists.
In many cases, non-healthcare practitioners are buying cheap Botox online or obtaining supplies from online consultations with medics which they are then injecting into customers.
There are no restrictions on purchasing or administering dermal filler, because it is not a drug.
Ashton Collins, director and founder of the campaign group Save Face - set up in 2014 to lobby for tighter restrictions on the cosmetic sector across the UK - said: "You will be able to go onto Instagram today and find dozens of clinics in Scotland which will give you Botox on the day.
"They're not healthcare professionals, you won't see anybody other than them, and that's going on all throughout the UK.
"That's our frustration because there really should be no clinics in Scotland that offer Botox that aren't operating from a HIS-regulated clinic, because if they offer Botox they need a prescriber and that clinic or that salon should therefore be a registered HIS premises.
"HIS know this, Scottish Government know this, but they acknowledge that HIS have not got the resources or the teeth to be able to enforce those rules properly, and they don't know how many people are not registered with them that should be.
"We raised grave concerns about it in 2016. We said 'you are starting with regulating the regulated' when it's the non-healthcare professionals who pose the greatest risk to the public.
"Eight years on, that landscape hasn't changed."
Ms Collins said that over the past 10 years, Save Face has handled around 15,000 complaints from the public of which an average of 85% related to non-healthcare professionals.
She said they tended to operate "like ghosts" with mobile practices visiting clients at home, advertising via social media, ignoring and blocking customers who complain about adverse effects, and repeatedly closing their profile pages only to pop up with a new identity to avoid being traced.
Ms Collins said: "At the moment, throughout the UK - not just in Scotland - you've got non-healthcare professionals offering extremely dangerous procedures like liquid [Brazilian butt lifts].
"People are nearly dying from these.
"We've seen people doing surgical liposuction who a couple of weeks before were working in retail. It's ridiculous.
"In about 50% of the complaints that we've managed, people have had sepsis.
"Luckily they've gone to hospital just in time, but we are calling for a blanket ban on high-risk procedures by non-healthcare professionals.
"What we're seeing now is that non-healthcare professionals are buying things like Botox and fillers from China and Korea at very cheap prices and importing it.
"There is no healthcare involvement whatsoever, and we're seeing horrendous complications from people who think they've had Botox but God knows what it is.
"We investigated one case where it turned out to be beef gelatine.
"Someone was buying 'Botox' from China - he thought it was Botox, it obviously wasn't - and 15 women had anaphylactic reactions and were rushed to hospital.
"We worked with the police to make sure they went in and seized that product."
The UK's cosmetic surgery industry is currently worth an estimated £3.6 billion.
Non-surgical treatments such as Botox and filler injections account for 90% of the market - around £2.75 billion.
While campaigners such as Save Face would like to see non-healthcare practitioners outlawed from the sector, most expect that changes in legislation may only go so far as requiring businesses to employ a prescribing healthcare professional in a supervisory capacity.
Current sanctions are limited to trading standards laws, enabling local authorities to prohibit companies found to pose a risk to public safety from operating within that region.
In May, Glasgow City Council banned two unnamed firms from carrying out non-surgical Brazilian butt lifts (BBLs) in the city.
The prohibition notice was issued to one of the firms after environmental health officers found that there were insufficient health and safety measures in place to protect patients, while a separate firm and the "celebrity aesthetics practitioner" behind it were banned after a woman was hospitalised following the procedure at a weekend pop-up clinic run out of a hotel conference room.
The woman paid £2000 for the procedure which inserted 500ml of filler into each buttock via a cannula on March 30, but ended up in hospital for five days after developing a potentially deadly infection.
Emergencies
Dr Demosthenous, who worked in trauma and orthopaedic medicine before moving into aesthetics, said practices such as his were seeing an increasing number of patients seeking help for botched procedures as well as complications which were "getting more serious" over time.
He said: "Sometimes it's poor aesthetic outcomes - lumps, irregularities, asymmetry - so it looks bad. But there's certainly been a few emergencies.
"We're seeing more serious complications because [non-healthcare practitioners] are becoming more confident and arrogant in their skills. There's minor surgical procedures being done.
"I had to treat a patient who had a raging infection following a thread-lift by a hairdresser.
"I know that another clinic in Edinburgh had to deal with a similar case by the same person but they end up having to send them to plastics at the hospital to be treated with IV antibiotics because the infection was that bad."
A thread lift facial - sometime nicknamed the "lunchtime lift" - uses medical-grade threads inserted into the skin to tighten and lift the face or neck.
As the threads dissolve they trigger an inflammatory reaction which results in a surge in collagen, helping to restore a more youthful appearance.
The procedure is quick, with minimal downtime, but it can cause complications including nerve injuries and infections.
Dr Demosthenous said he is also aware of a woman who "nearly lost her arm and her life" as a result of complications from Botox injected at a gym in the capital.
He said: "The patient hadn't seen a doctor, nurse or dentist, but she was given a prescription drug by someone who shouldn't be carrying a prescription drug.
"She [the practitioner] was taken to court, but she had a certificate to say she was trained in giving a Kenalog [steroid injection], so for some reason it was fine.
"But these certificates don't hold up - anyone can start a training course.
"I have an ex-patient who was an adult entertainer and she really wants to get into aesthetics.
"She keeps messaging me saying 'I heard if I do my Level 7 qualification I'll be okay', or 'if I do my ultrasound course I'll be covered' - and it's all lies.
"It's lies that are created by non-medics who are charging tens of thousands of pounds to train someone - but they're not adequately trained.
"If I were to go and perform a facelift I should be locked up. Just because I'm a doctor, doesn't mean I can do a facelift - I'm not trained in plastic surgery.
"But people do a course and think 'I know how to inject now'.
"The Government has to draw a hard line and they have to say that doctors, nurses, dentists, are the only ones who can perform these treatments."
'Paradox'
Mr Alastair Lowrie, an NHS plastic surgeon and the Scotland representative for the British Association of Aesthetic Plastic Surgeons (BAAPS), said the current regulatory system had created a "paradox" of expensive fees and overheads for the highest trained practitioners, and none for those most likely to cause harm to patients.
Mr Lowrie, who specialises in facelifts and rhinoplasties - colloquially known as 'nose jobs' - in his private cosmetic work at hospitals in Stirling and Livingstone, said a system intended to protect consumers was instead encouraging them to risk their health.
He said: "When Botox and fillers came out, patients used to think they were new and tricky and they would get a consultant to do them.
"Then, as it got more and more common, they just thought 'anyone can do this, dead easy'.
"More providers became available and the price dropped due to competition.
"Now there's no sort of value in the skill of doing it and patients will seek out the least expensive provider, but the ones HIS are regulating are the 'good guys'.
"There's a paradox in that the best UK surgeons pay a great deal of money every year to be regulated, and every time there's a crisis they seem to increase the regulation on the people who are already regulated.
"It's created this situation where to get treatment by regulated people, the public has to pay a lot of money, so there's an increased incentive for unregulated, unsafe practitioners doing it on the cheap.
"HIS only regulate clinics run by a registered healthcare practitioner, so they'll only regulate you if you're a nurse, a doctor, a dentist, or a dental nurse. If you're a beautician, HIS won't regulate you.
"HIS charge something like £3,500 for initial regulation, and nearly £2000 a year thereafter.
"If you're doing Botox as a nurse you're maybe charging £200, so £5000 is a lot of Botox to do before you've broken even.
"Whereas, if you're not a healthcare practitioner, for example you are a beautician, then there is no regulation and no fee."
In a consultation launched in October last year, the Scottish Government proposed doubling the registration fee for independent clinics from £3,500 to £7000 after HIS warned that its current income from fees was not enough to keep pace with growth in the independent healthcare sector and the costs of regulating it.
In 2022/23, the Scottish Government agreed to provide £260,000 annually to plug the shortfall until a solution is found.
Donna Maclean, chief inspector at HIS, said: “When we first started out as the regulator for independent healthcare clinics there wasn’t much information on the size of the industry in Scotland and what types of treatment they were providing.
"It is correct to say that range and types of treatment provided has continued to grow over the last few years and that requires our staff to be able to respond to understand what potential safety concerns there might be and to ensure that the clinic has thought about these concerns and responded appropriately.
"Moreover, it is not just the clinics providing cosmetic interventions where the industry is expanding – there are also more and more clinics providing treatments of various different types.
"For example, dentists, GPs, weight management and travel vaccination clinics – the list is regularly increasing.
"This also requires our team to have an understanding of how we need to regulate that service and to understand what good care should look like for them."
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Ms Maclean said HIS "completely understand and appreciate" the frustrations of healthcare practitioners.
She said: “There are hundreds of clinics in Scotland registered with us where staff are appropriately trained and carrying out cosmetic treatments to a high standard.
"We understand also that it’s not just frustration they feel, but genuine worry and concern for those individuals receiving treatment from people who may not be properly trained to deliver the treatments correctly, may not be using products that are licensed and approved in the UK, and do not have access to medicines and healthcare professionals to provide medical treatment if something goes wrong.
"We hope that an appropriate form of regulation is decided upon for those non-healthcare professionals.
“In the meantime, we would urge anyone looking to get cosmetic interventions to think about their health and wellbeing, and put their care into the hands of professionals with years of appropriate training and experience behind them, and where you can trust them to make your needs a priority.
"We would support any measure that helps to ensure that patients are kept safe.
“We believe that the best way for the public to stay safe is for cosmetic treatments to be provided from regulated providers, by appropriately trained and qualified healthcare professionals.
"People should always check that a clinic is registered with Healthcare Improvement Scotland before undertaking treatments.”
In Aberdeenshire, cosmetic nurse Linda Strachan fears that governments across the UK have dumped cosmetic regulation into the "too difficult" box.
Ms Strachan, who runs her own aesthetics business in Inverurie and has recently stepped down after five years as the Scotland rep for the British Association of Cosmetic Nurses (BACN), said patients should regard cheap Botox like fake designer handbags.
She said: "There's a massive influx of counterfeit product.
"You've got online pharmacies offering slashed-price dermal fillers claiming that it's genuine product when it isn't.
"You've got people going online seeing Botox for £50 instead of £150 and thinking they've found a bargain.
"People wouldn't buy a Gucci handbag for £50 because they'd know it was fake, but they'll buy Botox.
"We know people are using products that aren't licensed for use in humans, coming from Korea and China.
"We're seeing footage of non-sterile 'laboratories' - more like factories - churning out counterfeit dermal filler that end up in some of our salons.
"Same with liposuction: I've seen videos on Instagram and TikTok of really invasive procedures happening in beauticians without the correct care.
"They're doing surgical procedures in hair salons. So many things could go wrong - it's horrific.
"The government tell us they know they need regulation, but they 'have to get it right'.
"But while we're doing nothing, there's more and more types of products and procedures coming onto the market, and greater and greater harm potentially happening to people.
"It's going to take someone dying."
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