Medico-legal patterns of cosmetic malpractice: a comparative analysis of complaints and judicial outcomes between licensed and unlicensed providers in Shiraz, Iran

Abstract

Background

The global surge in cosmetic procedures has been accompanied by a rise in medical malpractice litigation. Cosmetic services differ fundamentally from therapeutic medicine in their elective nature, heightened patient expectations, and the growing participation of unlicensed providers, each contributing to distinct patterns of adverse outcomes and varying levels of judicial accountability. Therefore, clarifying the distinct risk patterns and legal consequences between medically qualified professionals and unauthorized providers is of critical importance; this research gap has been addressed in the present study.

Methods

This retrospective cross-sectional study reviewed 525 medical malpractice complaint records registered at the Shahid Ghodosi Judicial Complex in Shiraz, Iran, between 2021 and 2023. Records were screened according to predefined inclusion and exclusion criteria. Data were extracted from judicial case files using a structured checklist including demographic, clinical, forensic, and legal variables. Descriptive statistics and the Fisher-Freeman-Halton Exact Test were performed using SPSS version 25.

Results

Of the 525 medical malpractice records reviewed, 253 (48.1%) met the eligibility criteria and were included in the final analysis. Statistically significant differences were observed between licensed and unlicensed providers across clinical outcomes, service settings, and judicial penalties (p < 0.001). Licensed providers were involved in 74.3% of cases and were primarily associated with technical complications in surgical procedures, particularly rhinoplasty (27.1%), leading mainly to structural deformities (86.4%) and dissatisfaction with aesthetic outcomes. In these cases, “Diyah” (financial compensation) alone was the predominant judicial outcome (96.8%). In contrast, unlicensed providers (25.7%) were significantly associated with minimally invasive procedures such as fillers and Botox (40.0%), frequently performed in informal settings including private homes (53.8%). These interventions were mainly linked to infections and tissue necrosis (62.2%) and resulted in significantly harsher judicial penalties, including imprisonment (52.3%) (p < 0.001).

Conclusions

Licensed and unlicensed providers exhibited distinct malpractice patterns and judicial outcomes. Licensed providers were primarily associated with technical complications resulting in Diyah penalties, whereas unlicensed providers were linked to severe adverse events in informal settings and harsher sanctions, including imprisonment. These findings highlight the need for targeted regulatory and patient-safety interventions.

Trial registration

Not applicable.

Background

The global demand for cosmetic procedures has increased substantially over the past decade, transforming aesthetic medicine into a rapidly expanding healthcare sector [1–3]. However, this growth has been accompanied by a considerable rise in medical malpractice complaints and litigation, making patient complaints critical indicators of healthcare quality and patient safety in this elective, outcome-oriented sector [4–9]. Unlike therapeutic medical interventions, cosmetic procedures are uniquely susceptible to legal disputes over technical complications and inadequate informed consent [7, 10–12].

Iran is considered one of the leading countries in cosmetic surgery utilization, particularly for rhinoplasty [13–15]. The increasing commercialization of cosmetic services has expanded procedures beyond regulated medical settings, particularly into informal environments with limited professional oversight [16–20].

In Iran, malpractice consequences are addressed through a specific medico-legal framework involving Diyah, imprisonment, and monetary fines depending on the severity of the violation [21]. Diyah is a form of monetary compensation prescribed under Islamic law (Sharia) that an offender must pay to the victim or their heirs in cases of unintentional bodily injury, disability, or death [21, 22]. Although the economic and legal burden of medical malpractice has been widely discussed in international healthcare systems [23–25], evidence regarding the specific medico-legal characteristics of cosmetic malpractice in Iran remains limited [26, 27].

Previous Iranian studies have primarily focused on malpractice committed by licensed physicians within formal healthcare settings [28, 29]. However, few studies have comparatively evaluated complaints involving both licensed and unlicensed providers, despite significant differences in procedural settings, adverse outcomes, and judicial consequences [9, 30, 31]. This lack of comparative evidence limits the ability of policymakers and regulatory authorities to develop targeted strategies for improving patient safety and strengthening oversight of cosmetic services. Specifically, comparing licensed and unlicensed providers is essential because their involvement in different procedure types, service settings, and adverse outcome profiles generates fundamentally different risk trajectories—ranging from civil technical negligence to criminal safety violations—with correspondingly divergent judicial consequences that require targeted policy responses.

Therefore, the present study aimed to investigate the prevalence, underlying causes, and legal outcomes of complaints related to surgical and non-surgical cosmetic services in Shiraz, Iran. By comparatively evaluating both licensed providers and unauthorized practitioners, this study seeks to provide comprehensive evidence of the medico-legal challenges associated with cosmetic services to support evidence-informed regulatory and patient-safety interventions.

Methods

This retrospective, record-based cross-sectional study was conducted using judicial complaint records archived at the Shahid Ghodousi Judicial Complex in Shiraz, Iran, between 2021 and 2023. This complex is the primary judicial authority for medical malpractice and unauthorized medical interventions in the region. The unit of analysis was the judicial complaint file, representing a legally documented dispute regarding medical malpractice or unauthorized medical intervention in cosmetic services.

A census sampling approach was employed, whereby all judicial complaint files registered within the study period were screened. Initially, 525 malpractice files were identified. To ensure transparency and minimize selection bias, the following criteria were applied:

• Inclusion Criteria: Files were included if they (1) specifically concerned surgical or non-surgical cosmetic procedures; (2) contained a finalized judicial verdict; and (3) provided a complete forensic medical expert report.

• Exclusion Criteria: Files were excluded if they (1) were related to other medical specialties (e.g., general surgery, obstetrics, internal medicine); (2) were still pending or lacked a final judicial ruling; (3) had missing core data (e.g., unknown legal outcome); or (4) were closed due to the complainant’s withdrawal (non-prosecution).

After the screening process, 272 files were excluded primarily because they were unrelated to cosmetic services (n = 241) or had incomplete documentation (n = 31), resulting in a final analytical sample of 253 judicial complaint files. Since this was a complete census of all available records in the specified timeframe and setting, a sample size calculation was not applicable.

Data collection was conducted through an objective, systematic review of finalized judicial case files. To ensure reliability and minimize subjective interpretation, a structured data extraction checklist was developed and pilot-tested on a limited number of records to ensure the accuracy of data recording, two trained researchers independently extracted information from archived court documents, forensic medical opinions, and final judicial verdicts. All information was extracted directly as documented in the files. Variables including complainant/defendant demographics, procedure types, and settings were classified according to the official legal terminology of the Islamic Penal Code of Iran to ensure consistent and standardized data categorization.

The extracted variables included demographic characteristics of complaints (age, sex, marital status, education, occupation) and defendants (age, sex, specialty, licensure status).

Characteristics related to the cosmetic service were meticulously extracted, including the type of service provided (categorized into surgical procedures like rhinoplasty and abdominoplasty, or non-surgical interventions such as Botox and fillers) and the place of service delivery (hospital, clinic, private office, or private home.

• License status: licensed medical professionals and unlicensed individuals.

• Forensic Classification: Categorized into four legal types: (1) lack of skill (technical incompetence), (2) negligence (omission of duty), (3) non-compliance with governmental regulations, and (4) unauthorized medical intervention (practicing without a medical license).

• Legal Outcomes: Judicial penalties including Diyah (financial compensation), imprisonment, monetary fines, or combination sentences.

Data were analyzed using IBM SPSS Statistics version 25.0. Descriptive and inferential statistical analyses were performed using frequencies percentages, and comparative analyses. The normality of continuous variables was assessed using the Shapiro–Wilk test. Given the non-normal distribution of age, the Mann–Whitney U test was used for group comparisons.

To examine associations between categorical variables (e.g., licensure status vs. settings and outcomes), the Fisher-Freeman-Halton Exact Test was utilized. This test was specifically chosen because more than 20% of the cells in the contingency tables had an expected count of less than 5, necessitating an exact analytical approach for sparse data. A two-tailed p-value < 0.001 was considered statistically significant to reduce the risk of Type I errors during multiple comparisons.

The study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Ethics Committee of Shiraz University of Medical Sciences (Ethics code: IR.SUMS.NUMIMG.REC.1403.099). Official authorization to access archived records was granted by the Judicial Organization. Since the study used anonymized retrospective records, the requirement for informed consent was waived.

Results

Study population and complaint characteristics

A total of 525 judicial complaint files related to medical malpractice were initially screened, of which 253 files (48.1%) specifically related to cosmetic procedures were included in the final analysis. The remaining 272 files were excluded primarily because they were unrelated to cosmetic surgery or contained incomplete judicial documentation. Among the included records, 74.3% involved licensed medical professionals, while 25.7% were related to unlicensed individuals. Demographic and professional characteristics of complainants and defendants are consolidated in Table 1 to provide a clear comparative overview. Analysis showed that complainants were predominantly married, university-educated women (85.0%) with an average age of 36.43 years, whereas defendants were mostly male (68.8%) with an average age of 45.38 years and surgical specialists (41.1%).

Table 1.

Demographic characteristics of complainants and defendants in cosmetic service malpractice cases in Shiraz

Variable	Category	Complainants (%)	Defendants (%)
Gender
	Male	15.0	68.8
	Female	85.0	31.2
Marital status	Single	37.9	—
	Married	58.1	—
	Divorced	4.0	—
Education level	Below diploma	11.9	—
	Diploma	31.2	—
	Associate degree	8.7	—
	Bachelor’s degree	38.7	—
	Master’s or higher	9.5	—
Occupation	Employee	19.4	—
	Student	5.5	—
	Self-employed	32.4	—
	Housewife	42.7	—
Specialty type	General practitioner	—	7.9
	Specialist	—	22.5
	Subspecialist	—	5.5
	Surgeon	—	41.1
	Paramedic	—	2.0
	Non-medical individual	—	20.9
License Status	licensed	—	74.3
	unlicensed	—	25.7

Clinical characteristics and adverse outcomes

A significant statistical divergence was observed in the types of cosmetic services provided based on the provider’s licensure status (p < 0.001). Licensed providers were primarily associated with invasive surgeries, such as rhinoplasty (27.1%) and abdominoplasty (17.0%). In contrast, unlicensed practitioners focused on minimally invasive but high-demand interventions, including Botox and filler injections (40.0%) and facial lift procedures (29.2%) (Table 2).

Table 2.

Relationship between type of cosmetic service and licensure status of providers in Shiraz (2021–2023)

Type of service	Licensed providers (%)	Unlicensed providers (%)	P-value
Facial, temple, and submental lift	7.4	29.2	< 0.001
Botox, filler, and fat injection	8.0	40.0	< 0.001
Breast augmentation	8.5	1.5	< 0.001
Abdominoplasty	17.0	4.6	< 0.001
Rhinoplasty	27.1	1.5	< 0.001
Hair and eyebrow transplantation	9.0	0	< 0.001
Blepharoplasty	5.9	9.2	< 0.001
Laser hair removal and freckle treatment	3.2	12.3	< 0.001
Dual procedures	11.7	1.5	< 0.001
Other procedures	2.1	0	< 0.001

Regarding clinical outcomes, licensed providers were significantly more associated with structural deformities (86.4%). Conversely, unlicensed practice was found to pose a more severe safety risk, accounting for 62.2% of all cases involving infections and tissue damage, such as necrosis and scarring (p < 0.001) (Table 3).

Table 3.

Relationship between causes of complaints and licensure status of providers in cosmetic service cases in Shiraz (2021–2023)

Cause of Complaint	Licensed Provider (%)	Unlicensed Provider (%)	Significance (p)
Infection	77.8	22.2	< 0.001
Structural deformity	86.4	13.6	< 0.001
Functional impairment	85.3	14.7	< 0.001
Infection and tissue damage	37.8	62.2	< 0.001
Tissue injury	72.2	27.8	< 0.001
Death	100	0	< 0.001

Service settings and forensic classifications

Based on official forensic medical evaluations, “lack of skill” was identified as the leading type of malpractice (49.0%) for licensed practitioners, whereas “unauthorized medical intervention” was the primary charge for 22.9% of defendants, exclusively in the unlicensed group. The distribution of these incidents was found to be highly setting-dependent (p < 0.001). As illustrated in Fig. 1, licensed providers operated mainly within regulated healthcare infrastructures (58.0% in hospitals), whereas unlicensed individuals operated almost exclusively in informal settings, with 53.8% of their procedures performed in private homes.

Fig. 1.

Distribution of provider licensure status in cosmetic service cases across settings, Shiraz (2021–2023)

Legal outcomes and judicial consequences

The Iranian judicial system demonstrated a clear tiered approach to sentencing based on the provider’s legal status and the setting of the service (p < 0.001). For licensed providers, the legal outcome was almost exclusively civil in nature, with 96.8% receiving a Diyah-only (financial compensation) verdict.

In contrast, unlicensed practice was treated with significantly higher judicial severity, reflecting its classification as a criminal offense. As shown in Fig. 2, the majority of unlicensed defendants (52.3%) were sentenced to Diyah combined with imprisonment. Furthermore, the service setting was identified as a critical determinant of the final verdict; procedures performed in private homes significantly increased the likelihood of receiving imprisonment or criminal fines compared to those conducted in clinical settings (Fig. 3).

Fig. 2.

Distribution of legal outcomes across providers licensure status in cosmetic service cases, Shiraz (2021–2023)

Fig. 3.

Legal outcomes across service settings in cosmetic cases, Shiraz (2021–2023)

Discussion

The findings of this study provide a critical analytical framework for understanding the divergence between professional medical malpractice and criminal unauthorized interventions in the cosmetic sector. Unlike previous descriptive reports, our study demonstrates that the provider’s licensure status and the service setting are the primary determinants of both the clinical nature of complications and the severity of judicial outcomes [26, 29]. The finding that cosmetic-related complaints constitute approximately 48% of the total medical malpractice workload in Shiraz is substantial. This high prevalence underscores the massive burden of the aesthetic sector on the regional judicial and healthcare systems, aligning with international reports of escalating aesthetic litigation in rapidly expanding markets [1, 28, 32]. This suggests that the commercialization of beauty has made cosmetic services a primary source of medico-legal friction.

Licensed providers were primarily associated with structural deformities and aesthetic dissatisfaction, reflecting technical nuances or a gap between patient expectations and surgical reality [1, 30, 31, 33]. In contrast, complaints against unlicensed individuals were predominantly driven by severe safety failures, such as infections and tissue necrosis (62.2%), which signify a systemic lack of sterilization and professional oversight in unregulated environments [19, 20, 28, 34, 35]. The emergence of atypical infectious complications, such as iatrogenic mycobacterial infections or panniculitis from unregulated injections, underscores the extreme risks of the informal sector [36, 37].

The predominance of married, university-educated women among the complainants (85%), with housewives constituting the largest occupational group (42.7%), underscores a high degree of legal consciousness and heightened aesthetic expectations within this demographic [6, 9, 31, 38]. As the primary consumers of cosmetic services globally, women face disproportionate exposure to the psychological and physical risks of aesthetic complications [39–41]. Our findings suggest that higher educational attainment does not necessarily act as a protective barrier against the hazards of the unregulated aesthetic sector. This paradox is likely fueled by intense sociocultural pressures regarding body image and aggressive social media marketing that often targets housewives and intentionally obscures the legal status of unauthorized providers [34, 39, 40, 42]. Furthermore, the high representation of housewives suggests that this group may have more time and motivation to pursue formal legal redress when expectations are not met. Additionally, the unique Iranian cultural emphasis on facial aesthetics, specifically rhinoplasty [43, 44], presents a distinct litigation landscape compared to Western trends, where body contouring and breast surgery remain the dominant sources of medico-legal disputes [45–47].

The Iranian judicial system demonstrated a clear tiered approach to sentencing [48]. The near-universal application of Diyah-only verdicts for licensed physicians (96.8%) reflects the legal view of malpractice as unintentional negligence [21, 49, 50]. Conversely, the high rate of imprisonment for unlicensed providers (52.3%) reflects a judicial stance that treats unauthorized medical intervention as a criminal offense, a principle also observed in other sensitive areas of Iranian medical jurisprudence [48, 51, 52]. To bridge this gap, as established in studies of organizational reform in Iran, adaptive governance structures are essential to align judicial penalties with proactive health system oversight [22, 25, 26, 53].

Addressing these challenges requires a dual strategy of regulatory reform and professional development. Adopting competency-based educational approaches is vital to reduce technical errors and improve clinical performance among licensed practitioners [52, 54–56]. For the unlicensed sector, inter-sectoral collaboration between health authorities and the judiciary is required to monitor informal settings like private homes, which our findings identified as high-risk environments for both clinical complications and severe legal penalties [24, 28]. These interventions must be supported by continuous adaptation of medical university structures to ensure patient safety in a commercialized market [26, 27].

The data were obtained from a single judicial complex, which may limit representativeness of the broader population. The study was further restricted to cases recorded between 2021 and 2023 in a single city, thereby limiting temporal and geographic generalizability.

In addition, inclusion was limited to cases with final judicial rulings, introducing selection bias toward complaints that completed the full legal process. A substantial proportion of cosmetic complications and patient dissatisfaction cases are resolved at earlier stages, including forensic medical evaluations or private settlements, and are therefore not captured in judicial databases. This results in under-ascertainment of cases, and the findings should be interpreted as reflecting only the “tip of the iceberg” of adverse outcomes associated with aesthetic services.

Finally, the study did not compare primary and appellate court decisions, which may limit insight into variability in judicial interpretation across legal stages.

Conclusion

In conclusion, this study highlights a high prevalence of cosmetic malpractice complaints in Shiraz, reflecting a complex interplay between clinical technicalities and regulatory gaps. The findings reveal two distinct trajectories of malpractice: licensed providers often face litigation due to aesthetic dissatisfaction and technical complications, whereas unlicensed practitioners are predominantly associated with severe adverse events, such as infections and tissue damage, resulting from unauthorized interventions. The significant involvement of unlicensed individuals and the performance of procedures in non-medical settings (such as private homes) underscore a critical public health challenge and a significant breach of patient safety protocols.

From a health service management perspective, these results emphasize the urgent need for a multi-faceted approach to mitigate risks in the cosmetic surgery sector. Strengthening regulatory oversight, implementing stricter monitoring of non-medical environments, and enhancing the enforcement of licensing laws are essential. Furthermore, public health campaigns should focus on increasing awareness regarding the risks of seeking cosmetic services from unauthorized providers. Finally, promoting competency-based training and adaptive governance structures within the healthcare system can help reduce the incidence of technical errors and improve the quality of care in this rapidly expanding field.

Author contributions

Masoumeh Zamani Noudadi conducted the study, performed data analysis, and wrote the manuscript. Zahra Kavosi supervised the project, conducted the study and provided critical revisions to the manuscript. Mohammad Amin Bahrami and Fatemeh Mohabati assisted with data interpretation and reviewed the manuscript.

Funding

The authors declare that no funding was received for the conduct of this study or preparation of this manuscript.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was obtained from the Ethics Committee of Shiraz University of Medical Sciences (Ethics code: IR.SUMS.NUMIMG.REC.1403.099). Official permission was granted by the Judicial Organization to access and extract data from case files. Since only anonymized data from judicial and medical records were used, the requirement for informed consent was waived by the Ethics Committee.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.