In her bedroom, Gao keeps a small medicinal jar containing what she hopes will be key evidence for her lawsuit. Inside, submerged in formaldehyde, sit two pieces of cartilage that earlier this year were removed from her surgically resculpted nose. They don’t seem to fit the descriptions in her medical files, leading Gao to suspect foul play: was someone else’s cartilage inside her nose?

In March 2020, Gao went for her fourth nose job. Having started with cosmetic surgeries several years earlier, the 26-year-old dog shelter owner had found it hard to stop. “I just thought that the more I had done, the prettier I would look,” says Gao, whose deep-set eyes and sharp chin are the result of cosmetic procedures.

This time, a surgeon at a clinic in Suzhou, the city in the eastern Jiangsu province where she lives, would give her a more delicate nose. According to documents Gao showed Sixth Tone, the plan was for the doctor to use cartilage and other tissue from her ears, as well as a prosthetic implant. After the surgery, she realized, the doctor never touched her ears. But, happy with the outcome, Gao didn’t mind. She assumed the doctor had simply reused the piece of rib cartilage placed in her nose during an earlier procedure.

Eight months later, however, Gao’s nose became red and swollen. It was infected. Panicked, she wanted the clinic to help her, to undo the operation if necessary. Instead, she ran into a familiar outcome for Chinese cosmetic surgery patients who feel they have been wronged: she was stonewalled. The clinic refused to acknowledge any mistakes or offer a solution she considered adequate. With nowhere else to turn, she now faces a long and difficult legal process.

Gao is far from alone. Fueled by a Chinese public increasingly concerned about appearance and rigorous beauty standards that have been criticized as unhealthy, the country’s cosmetic surgery industry is going through a growth spurt. At the same time, there is a lack of qualified doctors and up-to-date regulations. The result is a white-robed Wild West dominated by cowboy clinics operating outside the law.

The consultancy iResearch predicted last year that, by 2023, China’s market for cosmetic surgeries will top 300 billion yuan ($46 billion) and cater to more than 25 million consumers. The company’s report also estimated that, in 2019, China had in excess of 80,000 illegal clinics, compared to just 13,000 lawful companies. Even at legal operations, things don’t always go by the book. Fifteen percent of those clinics and hospitals perform procedures they aren’t certified for. Meanwhile, the report says, many consumers underestimate the risks and degree of difficulty of cosmetic surgeries.

The result is a skyrocketing number of disputes. China Consumer Association, a government-affiliated organization, said in 2019 that the number of complaints about cosmetic surgery it receives per year had increased more than ten-fold since 2015.

From addiction to regret

Gao, who did not want to use her given name to keep her medical history private, began thinking about having work done on her face in 2014. Her friend, a beauty salon worker, had told Gao that her appearance was flawless, except for her nose.

“Her description made me pay more attention to my nose, and I started getting the idea that a nose job would make me look more perfect,” Gao says. She first tried injections of hyaluronic acid in her chin and nose. But their effects are only temporary, and she found the frequent injections too costly.

From 2016 to 2018, Gao underwent three nose jobs and three eyelid surgeries, as well as several skin-tightening treatments. Even though the results weren’t always entirely satisfactory, she couldn’t get enough. If something wasn’t quite right, another surgery would fix it, she thought.

But when her fourth nose job left her with an infection and other complications, she realized she had gone too far. Gao went to the clinic, the Suzhou branch of cosmetic surgery chain Mebel, eight times to negotiate with the employees there about a fix for her problems. But the only thing they would tell her, even when she brought a local newspaper journalist along, is that she had to take antibiotics, perhaps for the rest of her life. “Their indifferent answers made me so furious,” Gao says.

In January, the head of Mebel Suzhou, surnamed Ji, told a local newspaper that the doctor who performed Gao’s surgery no longer works with the company, and that, in any case, it would be difficult for a doctor to recall the specifics of a particular operation. Medical files are the most trustworthy, Ji said. “If it’s recorded in the medical files that cartilage was taken from the ear, then I believe that the surgeon really did that.” Mebel declined to comment when contacted by Sixth Tone.

Over the following months, Gao reported her case to the police and the local health authorities, without getting any tangible results. Online communities for victims of cosmetic surgery failures weren’t helpful either. In one chat group, only two out of over 300 members said they had successfully gotten some form of compensation. “They used extreme methods to push the clinics, such as pretending to jump out of the window, or sitting and crying in their lobby,” Gao says. Not willing to go to such lengths, she quit the groups.

She took antibiotics for two months, which gave her a hazy feeling and a face so swollen she barely recognized herself in the mirror, Gao recalls. She locked herself at home. Close to desperation, she started having suicidal thoughts. “I have been very concerned about my appearance since I was a little girl,” she says. “If I were really disfigured, what would be the meaning of life?”

Gao resolved to remove whatever was causing the infection from her nose. However, wherever she turned, physicians refused to operate, ostensibly wary of taking the blame if further complications arose. It wasn’t until late January that a doctor at a public hospital agreed to help her.

To Gao’s surprise, the doctor found only cartilage, and no prosthetic implant as Mebel claimed they would use. Gao became suspicious the clinic had substituted another person’s cartilage for her operation. She is in the process of filing a lawsuit against the company.

In February, shortly after Gao had the cartilage removed, Chinese actress Gao Liu — no relation — went public with her own cosmetic surgery mishap. She shared photos with her millions of social media followers that showed the tip of her nose had become a black stump, as if burned away by a flame, after first becoming infected post-surgery. The parallels between the celebrity’s case and her own shocked Gao. She felt a wave of lingering fear wash over her. “I’m lucky I made the right decision in time,” she says.

Cosmetic court cases

Key to disputes about cosmetic procedures are medical appraisals, wherein experts determine whether medical malpractice has taken place. Gao, for example, hopes this process will show whether the cartilage inside the medicinal jar is hers or someone else’s. In practice, appraisals only happen if they are court-ordered, which is one reason why people like Gao choose to file lawsuits. A local medical association can also commission an appraisal if both parties in the dispute agree to it. But clinics accused of misconduct rarely consent, leaving disputes unresolved.

Going through the courts is far from a smooth process, however. There are no country-wide figures for how many cosmetic surgery disputes end up in court, but in 2020 and 2021 two district courts in Shanghai and Beijing revealed they had handled 94 and 195 cases, respectively, in the five most recent calendar years.

Both courts said that the number of disputes over cosmetic surgeries has been trending up in the past few years, and that almost all the defendants are privately-run clinics. The Shanghai court noted that cases about medical surgeries are relatively complicated and usually take more time than other civil cases. Only 16% of cases ended with a verdict, and plaintiffs generally overestimate the compensation they can receive, the court said.

Court procedures are generally not well-suited for settling cosmetic surgery disputes, says Ru Xiaoshan, director of Yimeijing, China’s first mediation center for cosmetic surgeries disputes. Unlike regular medical procedures, where failure might result in obvious harm, judging the success of a cosmetic surgery can be highly subjective, Ru says. Patients seeking beauty also have a much lower tolerance for scars and other side-effects compared to people who, for example, broke their leg.

Established in 2018 under the supervision of the Beijing Law Society, a government-affiliated professional organization, Yimeijing proposes mediation as a better solution. Getting a resolution this way is often faster and more private than a lawsuit, Ru tells Sixth Tone. To break the appraisal stalemate, Yimeijing will have a panel of medical experts evaluate the procedure at the root of the dispute under mediation. So far, Yimeijing has handled over 1,200 cases; in more than 70% of them, both sides managed to come to an agreement. The center wants to establish branches in more cities throughout China.

However, Ru warns, mediation also has its limits. Yimeijing only accepts cases involving legal institutions and certified doctors. “Cases that involve illegal clinics and doctors would be transferred to law-enforcing departments such as police and food and drug administrations, and those cases will be handled with criminal charges,” Ru says.

In 2017, the Chinese government began a nationwide crackdown on lawbreakers within the cosmetic surgery industry. Within a year, authorities cracked 1,219 cases, arrested 1,899 suspects, and discovered 728 manufacturers of counterfeit drugs, the National Health Commission said. In June, the NHC announced another six-month campaign targeting unauthorized cosmetic surgery providers.

Ru, who helped Beijing health officials with the campaign, says it can be hard for law enforcement to track down small-scale illegal clinics. They might only operate for a short period of time before moving elsewhere, or don’t advertise openly and instead rely solely on word-of-mouth recommendations.

Another issue is that the regulations currently governing medical beauty treatments are almost 20 years old. In the meantime, the industry has changed dramatically, in no small part due to the internet. Violators also face lenient punishments — in the case of actress Gao Liu, a surgeon was suspended for half a year and the clinic was fined just 49,000 yuan.

Relying on periodic crackdowns and dispute mediation is not enough to tame the chaotic market, says Liu Feng, president of Yimeijing. “The current laws and regulations for the industry lag far behind the industry’s development,” he tells Sixth Tone, adding that his organization is helping the government update its regulatory approach.

Uneven results

Often, cosmetic surgeries take a while to heal, meaning it can be months, if not longer, before the final results of a procedure become pronounced. This can make it hard for some customers to tell whether they have been wronged.

For many years, Ma Jing didn’t know things hadn’t gone as they should when she went under the knife about a decade ago for double eyelid surgery, a popular procedure where a fold is created in the eyelid.

“When I was lying on the operating table, two doctors came in. When they started, I heard the younger one had to ask the older doctor’s permission for every next step,” Ma, now 33, recalls. It was her first cosmetic surgery. While she was confused, she didn’t question the doctors of one of the most reputable public hospitals in the central province of Henan. “I thought they were sending two doctors to get my surgery done faster,” Ma tells Sixth Tone.

But because different doctors worked on each of her eyes, they gradually became asymmetrical, with her left eyelid drooping lower and sometimes partly obscuring her view. Much to her embarrassment, people notice all the time. “Even friends of friends will judge me on the different sizes of my eyes, and some of them have even raised the question to my face,” Ma says. “It’s really humiliating.”

Only after talking about her experience with friends did she realize eyelid surgeries are usually performed by just one doctor. By then it was already too late. She tried to convince the hospital they had erred, but to no avail. Unlike Gao, Ma has given up on getting any kind of compensation from the hospital or the doctors involved. She doesn’t want to take legal action.

Ma just wants her eyes to look normal again. However, with an unsteady income from her maternity and infant store and young children to take care of, she can’t afford the 20,000 to 30,000 yuan for another operation. So she has resigned herself to camouflaging the difference between her eyes. “To make them look the same, I draw heavier eyeliners, use filters when taking photos, and I’m always mindful to lift my forehead,” Ma says. But even though she has mastered these techniques, sharp-eyed friends will still spot the asymmetry.

Sun, 28, had a similar experience. She underwent her first double eyelid surgery in her rural hometown in 2017. She had noticed many locals suddenly had puffy cheeks and deep-set, somewhat unnatural eyes. She was captivated.

Her hometown doesn’t have a public hospital with a plastic surgery department, but there was a clinic hidden in an office building, a friend told Sun, who didn’t want to use her given name out of fear her story might hurt her academic career. It seemed reliable. “The operation room looked more professional than the one where I had my tonsil surgery at a public hospital,” Sun tells Sixth Tone. The cost of the surgery, 2,000 yuan, was higher than procedures her friends had undergone, further boosting her confidence. A clinic employee promised Sun any unsatisfactory result could be fixed.

When the outcome did disappoint and she had the sutures removed, her eyes were nevertheless permanently affected. After one year, Sun could no longer bear walking around with uneven eyes. She found another clinic in Beijing, where she was pursuing her postgraduate degree at the time, and spent about 20,000 yuan on a second surgery. “For the second surgery the doctor told me that all they could do was improve it a little, but that already felt like a life-saver to me,” she says.

Sun didn’t hesitate and applied for a loan on payment app Alipay. “I simply thought 20,000 yuan is not a big amount of money,” she says. “But when I lived by myself, I realized that saving money is so difficult.” It took her about 18 months to repay the loan. Her eyes looked better at first, but still became uneven as time went by, with one eye developing a second fold. She decided she couldn’t afford a third surgery. She wasn’t sure she’d trust another doctor again, anyway.

Getting back to normal

“Many patients might think eyelid surgeries are simple, but that’s a misunderstanding,” Shi Lili, a plastic surgeon who has over ten years experience doing eye surgeries, tells Sixth Tone. “Surgeries on the (skin around the) eyes are full of difficulties as eyes have both dynamic and static states.”

Shi works at Beijing-based cosmetic surgery clinic Full Link BeauCare Clinic. Every day, she does three or four eyelid surgeries and another two repair surgeries, which place even higher demands on the skills and experience of a surgeon, she says. During repairs, there is less tissue and skin to work with. And unless patients have documents to show what happened during previous procedures, Shi will have to deduct what took place. She says she won’t accept patients coming in for repair operations whose expectations are too high.

“We found that for more than 80% of cases in which an illegal operation went wrong, repair isn’t possible,” said Ai Xiaoyu, an employee of SoYoung, one of China’s largest online communities for cosmetic surgery patients, at a press conference earlier this year. “They will have physical deformities for the rest of their lives, and many of them have suffered enormous psychological trauma that means they don’t dare lie down on the operating table again.”

SoYoung initiated a non-profit project in May 2020 to help victims of illegal cosmetic surgeries and accidents as well as people with congenital abnormalities. “It is our wish that everyone can enjoy the right to be an ordinary person,” a SoYoung spokesperson tells Sixth Tone. In one year, the company received over 440 applications and paid for surgeries for about 25 people.

Sun was one of them. She was operated on in January, and remembers feeling elated at the prospect. “I just wanted to have ordinary eyes, so that nobody would humiliate me anymore,” Sun says. Still recovering, she’s not yet sure whether she has achieved her goal.

Thinking back on her experience, she wonders what effect the ubiquitous advertisements for cosmetic surgeries would have on her if things had gone differently. “If my first 2,000-yuan surgery had been really successful, I can’t imagine how much I would be addicted to cosmetic surgeries,” Sun says.

Ma thinks people should be more tolerant of looks that don’t adhere to ideals. She has realized what made her opt for cosmetic surgery in the first place was her mother’s constant nagging. She works at a photo studio, and is often openly judgmental of people’s appearances. “She thinks I’m very ugly,” Ma says. Her mother is even critical about her grandchildren. But Ma tries to teach them a different lesson. “I told my kids that it’s okay for people to be concerned about how they look, but do not judge others,” she says.

Gao, whose nose got infected, also sees cosmetic surgeries in a different light. “After all these years, I finally realize that it’s really unnecessary to undergo so many surgeries,” she says. The implants in her nose put her constantly on guard. “When I went clubbing, I had to worry about whether anyone’s hand would hit my nose,” Gao says.

Now, her nose is almost back to normal, though Gao says it’s a little wider now than it was originally. All the attempts to improve her appearance cost her 400,000 yuan in total. In hindsight, she considers it a bit of a waste. “It’s enough to buy a small apartment. Isn’t that much better?” she says.

But Gao isn’t entirely done yet, either. She still undergoes minimally invasive procedures; she recently tattooed her eyebrows, eyelids, and lips. She has begun noticing many people on the street look a lot like her — as if they have undergone the same surgeries. So she’s thinking about doing something that will make her face stand out again.

“I’ve recently been considering tattooing a mole on my face,” she says. After consulting fortune-telling materials on the meaning of moles, she plans to have one over her eyebrow. “A mole that indicates wealth,” she says.

Editor: Kevin Schoenmakers.

In China, the Beijing Suicide Research and Prevention Center can be reached for free at 800-810-1117 or 010-82951332. In the United States, the National Suicide Prevention Lifeline can be reached for free at 1-800-273-8255. A fuller list of prevention services by country can be found here.

(Header image: Visual elements from SiberianArt/iStock/People Visual, re-edited by Ding Yining/Sixth Tone)