On this page:

• Cheaper, better?
• Tourist traps
• Risky business
• So, how much can you save?
• What to look for
• Case study

The cosmetic enhancement business is booming in Australia – industry estimates suggest it’s now a billion-dollar a year business. And just as it’s on the rise locally, it appears that more and more Australians are opting to have their breast augmentations, tummy tucks and liposuction performed overseas as a part of a package deal in locations such as Malaysia and Thailand.

ÌÇÐÄVlog takes a closer look at cosmetic surgery tourism to discover the highs and lows of a growing industry. 

Cheaper, better?

A large international study, the , estimated that Australians spend $300m a year on cosmetic surgery tourism, with an estimated 15,000 Australians heading offshore each year to go under the knife. Dr Meredith Jones from the University of Technology, Sydney, who worked on the study, told Australian Associated Press, “Most people are attracted to it because it is cheap overseas but the agents are beginning to tell us that they are servicing people who are choosing to go overseas because they think they will get better work done.”

Even Australian health insurer NIB is become a player in the market, offering  ‘NIB Options’. NIB Options is not a health insurance product but a fee-for-service which, according to their website, provides “safe and reliable choices for consumers wishing to undertake cosmetic and major dental procedures in Australia or overseas”.

A spokesperson from NIB said, “NIB Options is all about helping Australians to choose from a borderless network of surgical excellence as well as providing safety assurance”.

In Australia, the service only recommends members of the (ASPS) who have at least 12 years of medical and surgical education. For overseas procedures, it chooses only registered and certified surgeons with at least five years of postgraduate training and 12 years of medical and surgical education. NIB Options also offers an ‘after-care’ promise of 12 months’ support after surgery.

Tourist traps

Both the  (ACCS) and the ASPS say that cosmetic tourism trivialises invasive surgery and the decision should not be taken lightly.

“Surgical procedures and tourism should not appear in the same sentence,” says Dr John Flynn, the ACCS’s chief censor. “Surgery used to be very well considered and a serious proposition. It’s not something that you can add on to a holiday and it’s not something you do simply because this is the cheapest way to go.”

Flynn says the way most patients are connected with their surgeon – through a tourism travel company who is receiving commissions for referrals – is also problematic.

“There is no doubt that there are skilled surgeons,” he says. “But the issue is that patients in Australia do not have the opportunity to research the good ones overseas. You could potentially leave that choice in the hands of a travel agent.”

Risky business

Surgery is a risky proposition regardless of where it’s done, but Australian experts say there are additional risks to getting surgery in countries where regulation may not be as stringent as our own. The outcome could be results that you are unhappy with, or that cause a lot of pain and distress.

“Over the last few years we’ve seen an increasing number of people arrive as outpatients or at emergency departments with complications often related to breast implants, atypical infections… bad things like losing both nipples,” says Dr Anthony Kane, President of the ASPS. Kane says that although there are known complications associated with any surgery, he is seeing an increasing number of patients returning from South-East Asia with problems.

One of the biggest issues with having surgery overseas is if complications arise after returning home, when “the person who is best suited to treat your problem is several thousand miles away”, says Flynn. “Even if it might be the same type of complication that you might get in Australia, the most important thing is for the patient and the treating doctor to be in the same place.”

Revisions and corrections back home will add significant costs to your original bill, as would the expense of travelling back overseas to see your surgeon, especially if you’re unable to seek legal redress.

Australian experts warn of other potential risks of cosmetic tourism, including an increased risk of infections in tropical environments, implants that haven’t been through the same rigorous approval process as the Therapeutic Goods Association’s in Australia, and the increased risk of post-operative deep vein thrombosis during the long-haul flight home, which can be potentially life-threatening.

“There are surgical risks anytime you have surgery no matter where in the world the procedure is being performed,” says Cassandra Italia, managing director of Healthcare Hands, which calls itself an international patient concierge service. “It’s a patient’s responsibility to do their research in order to reduce those risks.”

So, how much can you save?

Often in Australia, cosmetic surgeons do not list pricing on their websites, with the caveat that costs will vary between patients and procedures. There are many costs associated with surgery – not just the surgeon’s fee – such as hospital or surgical facility costs, anaesthesia fees, medication and medical tests.

“There is no way that in Australia we can match the cost of surgery in Thailand or somewhere similar,” says Flynn. “In many cases it’s half the cost.”

Cassandra Italia says that patients can save “30–70%, depending on the hospital and expertise of the surgeon”, by having their cosmetic surgery done in particular countries.

For example, breast augmentation in Australia can cost around $10,000, while in Thailand you can pay less than $4000.

Travel and accommodation costs also have to be factored in, if they’re not part of a package deal, and the ASPS advises avoiding potential hidden fees by getting written financial details, including all out-of-pocket expenses for the surgeon, the anaesthetist, assistant and hospital theatre or facility costs.

“Surprisingly, there’s been many cases where costs are not that much different,” says Flynn. “And it’s surprising that people would save themselves [an amount] as small as a 20% improvement in price as a trade-off for the accompanying risk profile.”

What to look for

Before committing to any cosmetic surgery, it’s very important to do thorough research, ask for friends’ recommendations, and look for the surgeon’s qualifications, experience and national or international accreditation.

Most medical practitioners doing cosmetic work will describe themselves as either plastic surgeons or cosmetic surgeons. The names sound similar but they are very different.

Plastic surgeons

Plastic surgeons will:

• have a minimum of seven years’ additional training after obtaining their medical degree
• be registered as a fellow of the Royal Australasian College of Surgeons (RACS)
• have the letters FRACS after their name (to indicate Fellow of the Royal Australasian College of Surgeons).

Cosmetic surgeons

Cosmetic surgery is not a formally recognised specialty in Australia. Any general practitioner (GP) can call themselves a cosmetic surgeon and practise cosmetic surgery – whether they have additional surgical training or not.

While some cosmetic surgeons will be members of the Australasian College of Cosmetic Surgery (ACCS) and may have undertaken training provided by the college or studied overseas, none of this training is formally recognised.

While there are good cosmetic surgeons who have a lot of experience, it’s still important to know they do not have the formal qualifications of a plastic surgeon.

Cosmetic surgeons often use the letters FACCS after their name which is not a recognised credential and shouldn’t be mistaken for FRACS used by plastic surgeons.

In Australia, look on the  for an accredited plastic surgeon.

For surgeons overseas, look for one accredited by the Ìý(±õ³§´¡±Ê³§). , a website which offers consumer information about international medical and health travel, and NIB Options are also good places to start your research.

To help avoid the pitfalls of cosmetic tourism – and we’ve all heard the horror stories – the ASPS has compiled a list of things to look out for when contemplating cosmetic surgery overseas, which include asking the following questions:

• Is my surgeon a member of the ISAPS?
• Are the medical standards of care and quality control requirements at least as good as those in Australia?
• Have I been assured that the devices and products used in overseas hospitals meet Australian standards?
• Were the risks and complications explained to me?
• What will happen if things go wrong? Will the surgeon accept liability?
• Have I been told about post-operative care and what to do if complications arise after the surgery?

For the full list of questions, visit the .

Case study

Twenty-six-year-old Erica Gordon had a breast augmentation in Bangkok and told ÌÇÐÄVlog that she was happy with the result and felt in control of the whole process.

“I decided to have surgery overseas because I had several friends who had done the same and were very happy with the result,” she says. “The price was definitely a big factor which made me originally start researching. On [the agency’s] global website they had the history and qualifications of each surgeon, with ‘before’ and ‘after’ pictures [of their patients].

“Once you’ve selected your doctor and hospital, you can view their full details on the hospital’s website, which include where they studied, what degrees they have and what they specialise in. Also, the hospital I chose (Bumrungrad International Hospital) was listed as one of the top 100 in the world.”

Erica said the procedure came with an initial consultation three days before the surgery and another the day before. “Everything was disclosed, all questions were answered and professional recommendations were also made,” she says.

“I’m very happy. The only thing that was not perfect was one [breast] looked slightly bigger than the other, due to my chest bone sticking out on one side, which I was told by my surgeon would happen pre-surgery, so I was fine with that.”

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On this page:

• What is stem cell therapy?
• More information

Here we look at the stem cell therapy industry, which treatments have been proven to work and which to steer clear of, along with what action you can take to protect yourself against dodgy operators.

What is stem cell therapy?

We have lots of different types of cells in our body, such as muscle cells, bone cells, nerve cells, skin cells and so on. Stem cells are ‘mother’ cells that have yet to become a specialised cell type, and are able to divide and multiply indefinitely.

There are two main types:

• Adult stem cells, also called somatic or tissue specific stem cells, which are found in developed tissues and organs (skin, bone marrow, heart, brain etc.) and usually only give rise to the particular types of cell found in that tissue. Despite their name, they’re also found in infants and children.
• Pluripotent stem cells, a more primitive stem cell that is capable of developing into all of the different types of cells that make up our bodies. Embryonic stem cells, found in early developing embryos, are a type of pluripotent stem cell.

Bone marrow contains adult stem cells that have been used for decades to treat leukaemia and lymphoma and certain blood diseases. While the potential for embryonic stem cells to develop and multiply and ultimately replace faulty cells has been long recognised, ethical concerns – and legal restrictions in some countries – have to some extent constrained the development of treatments using embryonic stem cells.

But more recent developments in stem cell science – whereby already specialised cells, such as fat, blood or skin cells, can be induced to behave like embryonic stem cells – have opened up the field and its role in the future of regenerative medicine.

It’s these so-called induced pluripotent stem cells that are used in many of the stem cell therapies offered directly to consumers.

Regardless of the type of stem cells used, stem cell-based therapies can be broadly considered as autologous, where the patient’s own cells are used, or allogeneic, where the cells are from a donor. Induced pluripotent stem cells obtained from the patient’s own body are likely to be well-accepted by the patient’s immune system, as opposed to cells from other people which may be rejected.

While treatment using allogeneic cells are highly regulated in Australia, autologous therapies, and those in development, are not subjected to the same degree of scrutiny and regulatory oversight.

What conditions are claimed to be treated?

According to the Australian Academy of Science, there are around 60 practitioners offering unproven stem cell therapies in Australia, using direct-to-consumer advertising through websites and even radio ads, or word of mouth.

At present, there are very few conditions for which stem cell therapy is a proven treatment, and these include blood cancers (such as leukaemia) and other blood disorders, other cancers (such as Hodgkin’s disease and non-Hodgkin’s lymphoma) and some autoimmune disorders. In all cases the treatment involves the use of blood stem cells obtained from bone marrow or cord blood.

While there are legitimate clinical trials going on for many diseases and conditions, researchers investigating the stem cell therapy market in Australia have found it offered by private clinics in Australia outside of the clinical trials process for a wide range of diseases – including osteoarthritis and musculoskeletal pain, infertility, sports injuries, cancers, muscular dystrophy, multiple sclerosis, stroke, spinal cord injury, headache and migraine, asthma, autism, and cosmetic applications such as ‘facial rejuvenation’ and other anti-ageing therapies.

There are stem cell therapies offered outside the clinical trials process overseas, and recent years have seen the rise of ‘stem cell tourism’. Australians have travelled to countries including China, Russia, India, Germany, the US, Israel and Panama to undergo stem cell therapy for spinal cord injury, cerebral palsy, motor neurone disease and multiple sclerosis.

Experts point out that there is no reliable evidence that any of these procedures work, and many of the treatments on offer are considered experimental. While they may be scientifically plausible and may even have had indications of success in human subjects, they’re essentially unproven therapies. Some in fact claimed to be conducting research, although few had published their findings in reputable peer-reviewed journals.

But that’s not how it’s being sold to the public – leading experts in stem cell science have observed a large disconnect between marketing hype and evidence-based, scientific reality.

Stem cell therapy for cosmetic treatments and osteoarthritis – where’s the evidence?

The most common stem cell therapies offered in Australia are cosmetic treatments for anti-ageing and facial rejuvenation. A recent review of the state of the science for cosmetic stem cell therapy found that there is no good clinical evidence as yet for the use of stem cell injections for anti-wrinkle or anti-ageing treatments, although there is potential.

As for stem cell creams and lotions, take them with a grain of salt. They’re unlikely to contain live stem cells (as they can’t survive in the cream), so at best they may contain extracts from stem cells, or ingredients meant to stimulate your own skin’s stem cells. However, there are concerns that even these ingredients can’t survive indefinitely, and it’s not certain whether they can penetrate the skin barrier.

Despite their apparent harmlessness, Associate Professor Megan Munsie of Stem Cells Australia and the University of Melbourne is concerned about claims that various cosmetics contain stem cells. “It normalises the more extreme practices, reinforcing the notion that stem cells are somehow magical,” she says.

Many Australian clinics also already offer treatment for osteoarthritis and various other joint problems, despite a lack of conclusive evidence from clinical trials. A review on the safety and effectiveness of stem cell therapy for treating osteoarthritis found no good-quality, placebo-controlled trials published in medical literature.

Trials comparing stem cell therapy with other treatments, or simply comparing before and after, show some promise, but the nature (or lack) of the comparison groups make it difficult to draw firm conclusions about the effectiveness of stem cell treatment. The Australasian College of Sports and Exercise Physicians says more robust, peer-reviewed clinical evidence is required before stem cell treatments should be routinely provided to patients.

Safety concerns

Apart from lack of evidence, the safety of these marketed stem cell treatments is also questionable. Some of the adverse events arising from stem cell therapy include the development of tumours and abnormal bone growth, blood clots, paralysis, infection, allergic reactions, and even death.

Meanwhile, patients who opt to try stem cell therapies may discontinue conventional proven treatments or palliative care, and may find themselves ineligible to take part in properly administered clinical trials in the future.

Stem cell tourists face additional challenges, in that people who conduct stem cell therapy in other countries may not be suitably qualified, and there may be lower standards of hygiene and infection control. And if something goes wrong, options for legal or medical recourse may be limited or unavailable.

There are also concerns about the medical practitioners in Australia carrying out stem cell therapy. It may be the case that the doctor administering stem cell therapy has no formal training in that area of medicine. For example, a cosmetic surgeon attempted to treat a patient for dementia using stem cells from fat; the patient died due to complications.

Then there’s the inherent conflict of interest: due to the lucrative nature of the industry, stem cell providers may not make treatment decisions in the best interests of the patient.

Ultimately, consumers are forking out thousands of dollars – typical costs range from $10,000 to $60,000 – with very uncertain outcomes, and with little or no follow-up or aftercare. They may even be encouraged to come back and try again if their treatment hasn’t worked the first time.

What does the regulator say?

Unfortunately for consumers, the stem cell treatments proliferating in private clinics fall into a regulatory grey area. The Therapeutic Goods Administration (TGA), which is responsible for (among other things) regulating prescription medicines, medical devices, blood and blood products, specifically excludes from its jurisdiction autologous cell therapy where cells are taken from a patient and transplanted back into the same patient by a registered medical practitioner. This frames the treatment as a medical practice – subject to regulations concerning medical practitioners – rather than the provision of biological goods.

Stem Cells Australia, a multidisciplinary research collaboration of experts from around Australia, has called for the TGA exemption to apply not only when:

• the cells and other tissues are for autologous use,
• therapy is under supervision of a medical practitioner, and
• it’s for a single course of treatment;

as is currently the case, but also:

• provided the cells and tissues are not more than minimally manipulated,
• the cells are used in a way consistent with their biological nature (so stem cells derived from fat cells are used for post-mastectomy reconstructions, say, rather than to repair spinal cord damage),
• provided by dental practitioners as part of their standard practice, and
• therapies aren’t advertised directly to consumers.

Proponents of the status quo argue that increased regulation will stifle innovation and delay potentially life-saving therapies, and some have argued for self-regulation and oversight. However, Dr Munsie argues that improved regulation won’t inhibit the implementation of properly conducted clinical trials. Independent monitoring and oversight is essential to ensure patients are not placed at risk, but also that progress in the field isn’t compromised by those offering unfounded treatments in the name of stem cell science.

As the result of a review into stem cell treatments and advertising, the TGA announced some to take place in 2018. We don’t know the details yet, but indications are that procedures that take place outside of hospitals will be more tightly regulated, and advertising will be restricted.

What can consumers do?

If, having done your research, you’re interested in stem cell therapy for a particular condition, you could look at the  website to see if there are any clinical trials taking place that you’d be eligible to join. Better yet, discuss your options with your doctor – they know your condition’s history and current stage and, importantly, aren’t financially conflicted.

Some commercial clinics may suggest that you’re part of clinical research, or even call it a clinical trial, but unless the experimental intervention on offer is listed on a reputable clinical trial registry, it is unlikely to have been appropriately reviewed and approved. Even then, some clinics have started the controversial practice of registering treatments on the clinical trials register as case series, and they’re charging people to take part. So-called trials don’t have the same oversight as genuine clinical trials, and it’s on the increase overseas as well. 

Being asked to pay for the treatment should sound warning bells. If fees aren’t mentioned outright, look for ‘unfunded’ or ‘self-funded’ trials. Another red flag is a reluctance of the clinic to share data about the safety and effectiveness of the proposed treatment – and patient testimonials, blogs or ‘as seen on TV’ are not evidence a therapy is safe and effective.

Unlike commercial clinics, properly conducted clinical trials will declare their experimental nature upfront, as well as possible positive and negative outcomes. Patients are under the highest standards of medical care and are monitored throughout, given all necessary aftercare and long term follow-up. And patients aren’t charged for the treatment. Importantly, real clinical trials will have been cleared by an ethics committee, will have a consent form with a clearance number from the ethics committee and contact details. The absence of an ethics committee review is a major red flag.

If it’s already too late, and you’ve paid your money with no results – or bad results – it’s important to lodge a complaint. Perhaps understandably, people who’ve suffered at the hands of stem cell shonks often want to put the experience behind them rather than become embroiled in a long-winded complaints process. However, Dr Munsie believes that a lack of formal complaints is giving a false impression of consumers’ experiences with stem cell treatments, and is an excuse for the regulatory inactivity in Australia.

Complaints about the professional conduct of a medical practitioner can be made to the relevant board (doctors, dentists and various allied health professionals) via the Australian Health Practitioner Regulation Agency (AHPRA). Patients and/or their family members, as well as their concerned doctor, can lodge a complaint.

You can also complain to the commission in your state about a practice, clinic or hospital, as well as registered and unregistered health practitioners.

Consumers misled or deceived by claims suggesting a treatment was safe or effective may also have recourse under Australian Consumer Law, and are encouraged to lodge a complaint with their state’s fair trading department, or the Australian Competition and Consumer Commission (ACCC).

More information

is a multidisciplinary team of experts in bioengineering, nanotechnology, stem cell biology, advanced molecular analysis and clinical research, conducting research in stem cell science. It’s also involved in public education and research into ethical and legal aspects of stem cell science.

The Therapeutic Goods Administration (TGA) has a question and answer on stem cell therapy and regulation.

ÌÇÐÄVlog thinks that more needs to be done to protect consumers. Advertising needs to give consumers clear information about any proven benefits and likely harms. Regulators should be proactively monitoring what services are being promoted, rather than waiting for complaints, and should have the power to take quick, effective action in cases where useless or harmful treatments are being pushed at high cost to vulnerable consumers. 

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On this page:

• Different types of medical imaging
• Watch the build-up
• Exposing the costs
• Choosing a provider

Different types of medical imaging

Radiation is measured in sieverts (Sv) and accounts for both the amount absorbed and the sensitivity of different body parts to radiation. A millisievert (mSv) is one-thousandth of a sievert. To put this in perspective, radiation leakage at the Fukushima nuclear power station after Japan’s tsunami in 2011 was up to 400mSv/h (Sieverts per hour) between reactor buildings and 0.6mSv/h at the main gate.

We take a look at five common methods of medical imaging, what they are used for, and their typical dose of radiation.

• X-ray is the oldest, quickest and least expensive form of imaging. There is loss of fine detail in images of some soft tissues, because various structures are overlaid within the image.

Typical effective radiation dose: limbs 0.01mSv, chest 0.02mSv, abdomen 1mSv.

• Computerised tomography (CT) uses X-rays to reveal tissues with greater precision because the image is a cross-section, not an overlay. CT is best for the lungs and chest cavity in general. There are now lower radiation dose options.

Typical effective radiation dose: chest 8mSv, abdomen 10mSv.

• Magnetic resonance imaging (MRI) also provides high-quality cross-sections. Strong magnetic fields are used, avoiding the radiation associated with CT, but some medical devices such as pacemakers aren’t compatible. MRI is best for bones, joints, tendons, the spine and brain tumours.

Radiation dose: Nil.

• Positron emission tomography (PET) uses a scanning detector that shows the concentration of radioactive chemicals injected into the patient’s bloodstream. It may be used to identify areas of inadequate blood flow in the brain after a stroke.

Typical effective radiation dose: 5mSv (when not done in conjunction with CT).

• Ultrasound images are not high quality, but there is also no radiation. It’s commonly used to study abdominal organs, pelvic organs, some joints and breast tissue.

Radiation dose: Nil.

Watch the build-up

The idea that modern imaging equipment exposes patients only to modest radiation isn’t true of CT scans. Unnecessary chest CT scans could result in about 40 fatal cancers a year in Australia.

What’s really important to note is that exposure is cumulative, adding up over a lifetime and incrementally increasing the cancer risk. The young are most at risk.

To help limit unnecessary exposure to radiation, make sure the suggested method of imaging isn’t overkill – don’t go for a CT scan, for example, when an X-ray will be adequate.

Facts about radiation exposure:

• Normal background radiation dose is about 2.5mSv per year.
• A 13-hour flight could provide an additional 0.075mSv exposure.
• Airline crew may receive an additional 2mSv-5mSv exposure each year.
• A 1Sv (1000mSv) dose (received all at one time) equals a 5% increase of fatal cancer over a lifetime, and causes temporary radiation sickness.
• Exposure as a foetus, child or adolescent can double or triple this risk.
• Exposure over age 60 may reduce the 5% risk to about 1%, because potential cancer is less likely to manifest during the remainder of the person’s lifetime.
• An 8mSv chest CT has 400 times the radiation exposure of a 0.02mSv chest X-ray.
• A 10mSv abdomen CT may lead to an increased lifetime cancer risk of about 1 in 2000, and is called ”low risk”.
• A 1mSv breast mammogram, associated with a lifetime cancer risk somewhere between 1 in 10,000 and 1 in 100,000, is called ”very low risk”.
• A 0.01mSv limb X-ray has a “negligible risk” as it’s too small to quantify easily.
• CT scans should not be used where an X-ray is adequate, such as to confirm pneumonia has cleared in the lungs of a child.
• These risks represent small additions to the one-in-three chance we all have of getting cancer in our lifetimes.

Exposing the costs

Medical imaging is done by a radiographer, or a sonographer for an ultrasound. The image is evaluated by a radiologist, a specialty role that requires a medical degree and further study.

The Australian Medical Association ()’s suggested fees for medical imaging services are substantial, with big gap payments to match. Our investigations have shown that services generally don’t charge anywhere near the AMA’s recommendations.

GP-referred imaging is largely paid for by Medicare, which has a scheduled fee for imaging services and provides a payment for each one. Patients may also need to contribute directly when there is a gap between the Medicare rebate and the amount charged by the provider, or in rare instances, where no Medicare rebate exists. If a provider is prepared to accept the rebate as full payment, they can bulk bill Medicare, cutting the patient out of the payment process and reducing both administration and accounting costs. 

Choosing a provider

Discuss public and private options with your GP, but remember, regardless of the name on the referral, you can go to any imaging provider you choose. Public providers (and some private ones) don’t charge a gap. Among the private providers that do charge a gap, the out-of-pocket costs can be high, so shop around and don’t forget to check waiting times. A gap payment can be the trade-off if you want the convenience of a specific local private provider, with easy parking and no waiting. You can also ask your GP to request bulk billing, but they may choose not to.

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