New cosmetic surgery advertising guidelines

With the Medical Board of Australia (MBA) and Australian Health Practitioner Regulation Agency (Ahpra) announcing changes to cosmetic surgery advertising guidelines, including the removal of deceptive or misleading social media posts, to take effect from 1 July 2023, this is what you need to know. Collated by David Hickie.

The cosmetic surgery advertising guidelines apply to cosmetic surgery – defined as ‘operations that involve cutting beneath the skin and which revise or change the appearance, colour, texture, structure, or position of normal bodily features with the dominant purpose of achieving what the patient perceives to be a more desirable appearance’.

Examples include breast augmentation, abdominoplasty, rhinoplasty, blepharoplasty, surgical face lifts, cosmetic genital surgery and liposuction and fat transfer.

Gender affirmation surgery is not considered cosmetic surgery, and the cosmetic surgery advertising guidelines ‘do not apply to non- surgical cosmetic procedures’.

The MBA noted these new guidelines have been developed to address:

• the ‘unique features of cosmetic surgery not present in many other areas of medical practice’; and
• the ‘specific risks involved with cosmetic surgery advertising’.

The MBA emphasised ‘cosmetic surgery is invasive with potential complications, is often irreversible and is often sought by potentially vulnerable people. It can also be a lucrative area of practice and financial gain can compete with, and sometimes outweigh, patient wellbeing and safety considerations.’

Who is responsible for advertising?

• Responsibility for advertising content rests with the person in ultimate control of the advertising. In most cosmetic surgery advertising, this is the registered medical practitioner.
• Practitioners need to check any content produced by others on their behalf and ensure it is compliant.
• When someone other than a registered medical practitioner controls the advertising (for example, where the practitioner is an employee of a multi-disciplinary business), the practitioner is still obliged to ensure their cosmetic surgery services are advertised lawfully and appropriately.

What is considered advertising?

• Advertising includes, but is not limited to, all forms of verbal, printed and electronic communication that promotes and seeks to attract a person to a regulated health service provider and/or to attract a person to use the regulated health service (such as the cosmetic surgery service). Social media is often used to advertise a regulated health service. Content on public and private social media profiles or groups may constitute advertising under the National Law if the content relates to a regulated health service. This includes comments by the practitioner or other content from the practitioner.
• Advertising can also occur via: television or cinema; radio; newspapers; flyers; billboards; books (if the book is promoting a particular cosmetic surgery provider); pictorial representations; designs; mobile communications or other displays; all electronic media that promotes a particular cosmetic surgery provider; business cards, announcement cards; office signs and similar; letterheads on public- facing documents used to promote a particular cosmetic surgery provider; public and professional directory listings or similar professional notice (such as patient recall notices); internet, including websites and social media.

Role of advertising in cosmetic surgery

• Due to cosmetic surgery’s discretionary nature, advertising plays a significant role in driving demand. Social media advertising and/or other commercial business practices – such as up-selling additional procedures or treatments, or offering other inducements are used extensively to reach and influence consumer choice in cosmetic surgery. This is different from most other regulated health services which are driven by healthcare need.
• Advertising that does not accurately represent the health service provided, the risks, or the nature and scope of the service is unacceptable and is not appropriate in the context of invasive medical treatments, such as cosmetic surgery. It can mislead the public, create unrealistic expectations, may lead patients to seek out unnecessary or inappropriate cosmetic surgery, may downplay the seriousness of the surgery and/or the risk of surgery, or downplay the recovery time and recovery experience, and lead to poor healthcare decisions.

Good practice in cosmetic surgery advertising

• Good practice cosmetic surgery advertising:
  • gives balanced and accurate information so the overall impression created by the advertising is not misleading;
  • describes and/or shows realistic results;
  • presents the risks and recovery process accurately;
  • makes clear that outcomes will depend on the characteristics of the individual seeking surgery;
  • presents normal body variation positively without pathologising normal appearance or encouraging surgery to ‘fix’ normal variations.

Practitioner responsibility

• Cosmetic surgery must not be advertised in a way that exploits the vulnerabilities or insecurities of individuals to increase demand for cosmetic surgery. A practitioner’s duty of care to their patient is the paramount consideration in all practitioner-patient interactions, including through advertising.
• Practitioners must recognise there is strong demand from patients who are not suitable candidates for cosmetic surgery because of psychological issues, such as body dysmorphic disorder (BDD), and must recognise the potential harm to such individuals who may seek cosmetic surgery. Cosmetic surgery must not be advertised in a way that targets or drives demand from such individuals.
• Practitioners must recognise the potential for conflict between financial gain and their duty of care to patients. Practitioners must recognise cosmetic surgery may have a negative physical, psychological or financial impact on some patients, regardless of the skill of the practitioner.
• Advertising that includes information about costs or the availability of health insurance cover must be clear, easily understood, accurate, honest and include the total cost – not just the cost of consultations, but other costs such as anaesthesia and aftercare.

Titles & claims about training, qualifications, registration, experience & competence

• Only a registered medical practitioner who holds specialist registration in a recognised specialty may use the relevant specialist title in advertising. Only a registered medical practitioner who holds a type of endorsement can claim to hold or describe themselves as having that endorsement.
• All practitioners advertising cosmetic surgery must include clear and unambiguous information about their qualifications and type of medical registration. Information must include the practitioner’s registration number and whether they hold general registration or specialist registration, including recognised specialty and field of specialty practice (if applicable).
• Professional memberships can also be included in advertising. However, acronyms must not be used alone without explanation as this may mislead patients.
• Claims about a practitioner’s experience must be accurate and must not mislead the public as to the extent of a practitioner’s experience or training. For example, it is misleading to use surgical rotations completed during pre-vocational training to imply that a practitioner has undertaken accredited surgical training or has relevant surgical experience.
• Cosmetic surgery advertising must not use terms (including in taglines, hashtags and similar) that advertise the practitioner or the practitioner’s abilities in a manner that may be misleading or create unrealistic expectations. Examples of inappropriate terms include ‘magic hands’, ‘sculptor’, ‘god’, ‘king’, ‘queen’, ‘world’s best’, ‘world renowned’.

Financial & other incentives

• Cosmetic surgery advertising must not offer incentives, gifts, discounts or inducements that would encourage people to have cosmetic surgery. Examples of inappropriate incentives or inducements include:
  • giving a discount if a patient undergoes cosmetic surgery before a certain date;
  • offering benefits such as discounted airfares, accommodation or spa treatments as part of a cosmetic surgery package;
  • offering discounted packages or ‘bundling’ of multiple procedures (for example, ‘facelift and fillers’);
  • offering a gift or prize for promoting a particular medical practitioner or practice.

Testimonials

• The National Law specifically prohibits use of testimonials or purported testimonials, such as patient stories and experiences, success stories or fake testimonials, in advertising. Cosmetic surgery advertising must not use testimonials due to their potential to create unrealistic expectations of beneficial treatment.
• A testimonial is a positive statement about a person or thing. In the context of the National Law, testimonials are recommendations or positive statements about the clinical aspect of a regulated health service, that are used in advertising.
• A clinical aspect in a testimonial about cosmetic surgery would be any positive statement about the experience of, the reason for or the outcome of the surgery, or statements about the skills or experience of the medical practitioner, either directly or via comparison and could include linking to images showing surgical outcomes. This is because revision or change to appearance is the dominant purpose of cosmetic surgery.
• Practitioners are considered to have used a testimonial in advertising if they have published testimonials in their advertising, whether the advertising is in print, on a website or social media or displayed within a clinic. This includes where the testimonial is published in a time restricted way, such as through the use of social media platforms’ ‘stories’ function.
• Testimonials are also considered to have been used in advertising where a medical practitioner:
  • links to testimonials on third party advertising;
  • re-shares stories or posts from patients that are recommendations or positive statements about the cosmetic surgery and/or the medical practitioner who provided the cosmetic surgery; and/or
  • interacts with the review, such as liking or otherwise responding to a patient’s social media post.
• While practitioners are not responsible for testimonials or reviews their patients may post to third-party websites, practitioners must take steps to ensure they do not interact with, or allow testimonials to be published, when they have control of, or over, this function. Practitioners can minimise the risk of third parties posting testimonials and linking to the practitioner’s advertising by disabling reviews, comments or ’tagging’ functions on their page on social media platforms.
• The prohibition on using testimonials to advertise cosmetic surgery does not affect:
  – patients sharing information, expressing their views online or posting reviews on review platforms;
  • how members of the public can interact with review sites or discussion forums;
  • individuals or businesses that do not advertise a regulated health service.

Social media influencers & ambassadors

• The use of social media ‘influencers’, ‘ambassadors’ or similar increases the risk patients are not fully informed and form unrealistic expectations of results. The content published
  by social media influencers or ambassadors is considered to pose a particular risk to younger people due to the nature of the audience for some social media platforms.
• Practitioners or other advertisers who enter into any arrangements with social media ‘influencers’, ‘ambassadors’, content creators or similar individuals are responsible for the advertising content delivered by these individuals.

Use of images – including ‘before & after’ images

• Single images must not be used in cosmetic surgery advertising when the use of the image is likely to give the impression it represents the outcome of a surgery, as this can mislead the public, idealise cosmetic surgery and/or increase unreasonable expectations. Examples of inappropriate use of single images include naked bodies or body parts or bodies in lingerie or swimwear, stylised single images, such as those with ‘mood’ lighting, soft filters or black and white images, and images of models or celebrities.
• Images of people aged under 18 must not be used in advertising of cosmetic surgery.
• All images used in advertising that are intended to show the outcomes of cosmetic surgery must include a prominent warning that the outcomes shown are only relevant for this patient – and do not necessarily reflect the results other patients may experience, as results may vary due to many factors including the individual’s genetics, diet and exercise.
• Images used in advertising must be of actual patients who have had cosmetic surgery performed by that medical practitioner.
• ‘Before and after’ images must be presented so the most prominent or first image seen is either a combined or composite of both the ‘before’ and ‘after’ images or the ‘before’ image. Advertising where the ‘after’ image is the most prominent image may create unrealistic expectations.
• ‘Before and after’ images must be as similar as possible in content, lighting, camera angle, background, framing and exposure, posture, clothing and make up. This is to ensure the comparisons of ‘before and after’ images are genuine and are not influenced by factors such as the use of lighting, makeup, facial expression, clothing, or varied angles to improve the ‘after’ image.
• ‘Before and after’ images must not be edited or enhanced, for example through the use of filters, retouching, grey-scaling and similar techniques, as this can be misleading about the results of cosmetic surgery by minimising scarring and bruising.
• Photographs, videos or any other imagery must be used responsibly, for the purposes of information and/ or education about cosmetic surgery only. Some examples of features that are more likely to be considered to be focused on entertainment and to trivialise cosmetic surgery include:
  • imagery that includes music, dancing, singing, or comedic comments;
  • editing that is not directed at presenting information (such as a montage of cosmetic surgeries, cosmetic surgery outcomes and/ or bodies);
  • imagery with a voice-over where the voice-over is not educative or informative.
• The use and descriptions of photographs, videos and images must not:
  • idealise or sexualise cosmetic surgery through the use of sexualised images, such as poses suggestive of sexual positions, parting of legs, hands placed near genitals or positions that imply sexual readiness. Other examples of inappropriately sexualised images include photographs, videos or images showing sexualised clothing, such as lingerie or sexual paraphernalia, simulated undressing, such as pulling down underpants or a bra strap, oiled bodies and similar;
  • contain gratuitous nudity. For example, advertising must not include photographs, videos or images of naked breasts, even if censored, when presenting information about cosmetic surgery unrelated to the appearance of breasts;
  • use icons, such as emojis, to cover body parts for modesty or to indicate an emotional reaction to an image;
  • use lifestyle shots, for example, images taken on a beach, poolside, on a bed, chair, in a bedroom or hotel room;
  • capture, or purport to capture, emotional reactions of patients, such as patients giving ‘thumbs up’ or crying with happiness after cosmetic surgery in a photograph, video, or image;
  • use images accompanied by captions or descriptions that idealise cosmetic surgery or minimise the risk of cosmetic surgery. For example, ’more natural’, ‘hot’, ‘younger’;
  • name patients or contain links to a patient’s social media or other digital media account.
• Practitioners must prioritise patients’ interests, dignity and privacy ahead of marketing or advertising opportunities. Practitioners must:
  • have fully informed consent from patients, separate from the consent to surgery, to use their image in any advertising;
  • provide the patient with information about the proposed use of any images of them in advertising, including where the image will be used (for example, within the clinic, on social media, on billboards, etc), and for how long;
  • make clear to patients that any image of them used in advertising, particularly on social media platforms, may be used by or commented on by a third party without the medical practitioner’s or patient’s knowledge;
  • provide patients with an opportunity to view their images before consenting to the use of their image in advertising;
  • make clear to patients that they have a right to refuse use of their images and that they are not required to agree to the use of their images in advertising;
  • provide the patient with information about where the original images will be stored and who will have access to them;
  • store original images as specified by the Board’s Guidelines for registered medical practitioners who perform cosmetic surgery and procedures;
  • document the patient’s consent for taking, use and storage of any images;
  • make clear to patients that they are free to withdraw their consent for the use of their images in advertising at any time and provide clear information and a process for them to do so;
  • promptly remove patient images from their advertising whenever a patient withdraws consent to use their images.

Risk, recovery & idealising cosmetic surgery

• All cosmetic surgery is invasive and carries risks. Advertising must provide accurate, realistic and educative information about risks or potential risks. Failure to do so has the potential to mislead or deceive the public and to create an unreasonable expectation of beneficial treatment.
• Practitioners must ensure full information about risks and potential risks can be easily found within cosmetic surgery advertising. The public should not be required to exhaustively search for, or contact, the medical practitioner for information about risks and potential risks. It may not be possible in some advertising, such as social media, to provide full details about risks or potential risks of the cosmetic surgery. In this case the advertising should direct the public to the location of the information about risks or potential risks, such as through a link, or directions to the section of the medical practitioner’s website that contains the information.
• Practitioners must not offer cosmetic surgery as a competition prize, as this is not reflective of the thought, careful consideration and planning that should go into a decision to have cosmetic surgery.
• Cosmetic surgery advertising must include realistic information about recovery time and the recovery experience. This includes explaining any necessary recovery services, such as massages or compression garments, and expected or possible changes to lifestyle including absence from employment or temporary restrictions on activity.
• Advertising must not downplay recovery or mislead patients in relation to the experience of pain and recovery through, for example, describing cosmetic surgery as ‘gentle’, or ‘simple’ or describing the recovery process as ‘quick’ or ‘rapid’ when different patients will heal differently, and have different pain thresholds and will therefore experience different recovery times for different activities.
• Advertising must not trivialise cosmetic surgery. It must not:
  • minimise the invasiveness of cosmetic surgery (for example, the use of words such as, but not limited to, ‘artistry’, ‘silhouette’ and ‘sculpting’ are inappropriate in cosmetic surgery advertising);
  • mislead patients in relation to the surgery’s complexity, duration, expected pain, potential side effects or potential complications;
  • use emojis on images, in response to images, or in the text of the advertising;
  • use minimising terms such as ‘gentle’, ‘simple’, ‘safe’, ‘quick’, and/or ‘easy’;
  • use colloquial terms or non-clinical terms without also using the medical term for the surgery as this detracts from the seriousness of the surgery (including via a hashtag) for example, ‘boob job’, ‘tummy tuck’, ‘Brazilian butt lift’;
  • idealise cosmetic surgery through the use of images, words or other marketing techniques. For example, advertising must not use terms such as ‘designer vagina’, ‘barbie’, non-clinical adjectives such as ‘transformation’, ‘amazing’, ‘perfect’ and similar;
  • encourage interaction with images in a competitive way, such as promotional material that asks for votes on patients’ surgical outcomes or features such as ‘guess the size of the implant’.

Body image & promotion for wellbeing & improved mental health

• Not all patients have a realistic view of their body image. They may be unduly influenced by cosmetic surgery advertising because they are fixated on a normal physical variation or are suffering from body dysmorphia, low self-esteem, low life-satisfaction or low self-rated attractiveness. Practitioners must be aware that interventions other than cosmetic surgery may be better to address the concerns of such patients. Cosmetic surgery advertising must not suggest or give the impression that cosmetic surgery is the only option for individuals unhappy with their appearance.
• Cosmetic surgery advertising must not use automated apps, websites, tools or programs which predict an individual’s appearance post- surgery.
• Cosmetic surgery advertising must not:
  – encourage patients to undergo multiple surgeries at the same time (for example, through promotion of packages or ‘bundling’ of cosmetic surgery) as this may lead patients to have additional surgery they did not need or did not initially intend to undergo;
  • use language or statements which are exploitive, disapproving or imply that a normal change (for example, post-pregnancy body), body shape or bodily feature is abnormal or undesirable or is not aesthetically pleasing and can be fixed or created by cosmetic surgery. This means, for example, phrases or terms such as ‘mummy makeover’, ‘unsightly bulges’, ‘lose the bingo wings’, ‘flabby’, ‘problem area’, ‘hip dips’, ‘thigh gaps’, ‘flat buttocks’ and similar must not be used in cosmetic surgery advertising;
  • state or imply that it is normal to have cosmetic surgery to ‘fix’ natural variations and changes in body shapes and features;
  • focus on an individual’s negative feelings about natural variation in their body, body image or body part;
  • promote unrealistic images of youthful, ‘perfect’ body shapes; state or imply cosmetic surgery should be used to obtain an acceptable or ‘ideal’ body type. This includes:
    • using phrases that imply wellbeing will suffer without cosmetic surgery, such as ‘healthier, happier you’, ‘restore’, ‘youthful’, ‘best version of yourself’, ‘body goals’ and similar;
    • using non-clinical terminology such as ‘get ready for summer’, ‘bikini body’, ‘forever young’, ‘the body you deserve’, ‘work of art’ and similar.

Realistic expectations of outcomes

• Cosmetic surgery services must not be advertised in a way that creates unrealistic expectations of outcomes. Advertising must:
  • not use terms such as ‘magic’, ‘art’ or ‘sculpt’ that minimise the nature and risk of cosmetic surgery and may create unrealistic expectations;
  • not use statements or marketing techniques that imply any desired outcomes can be obtained. For example, phrases such as ‘get her look’, ‘bod inspo’, ‘bikini body’, or ‘get your desired shape’ and similar are all unacceptable;
  • be clear that individual responses and individual results vary as the outcomes experienced by one person do not necessarily reflect the outcomes that other people may experience, as results may vary due to many factors, including the individual’s genetics, diet and exercise.
• Cosmetic surgery advertising must not make claims about psychological or social benefit or similar claims which cannot be supported by acceptable evidence. For example, advertising that claims cosmetic surgery will change the patient’s life, boost confidence, improve body image or self-esteem or similar claims is not acceptable unless these claims can be supported by evidence that meets the standard for acceptable evidence in health advertising.

Targeting people potentially at risk

• Practitioners must recognise that children and young people, along with other specific patient groups, are particularly vulnerable to body image pressures and negative body image perceptions. Practitioners should recognise the potential risk of exacerbated body image dissatisfaction among vulnerable groups when advertising implies that a patient’s body image will be improved through cosmetic surgery.
• Cosmetic surgery advertising must not be targeted or directed at people under 18 and must limit the exposure of people under 18 by not advertising in publications or other media likely to appeal to, or have a significant audience of, people under 18. Cosmetic surgery advertising in social media must be identified as ‘adult content’ in order to prevent people under the requisite age from accessing cosmetic surgery content on the social media platform.
• Cosmetic surgery advertising must not exploit or be targeted towards at-risk groups. This includes not leveraging social media algorithms and similar to boost social media posts towards vulnerable groups. Cosmetic surgery advertising must not use terminology in meta data, hashtags, or other fields within advertising in order to target a vulnerable patient demographic.
• Practitioners must consider the frequency of their advertising and social media posts and recognise that excessive posting (for example, daily or multiple times a day) may contribute to body image dissatisfaction by creating the perception that it is normal to have cosmetic surgery. AMP