Of 2,777 clinics registered in South Korea as plastic surgery or dermatology practices, only 84 had an anesthesiologist on staff as of July — roughly 3 percent — despite the near-universal marketing of sleep-inducing anesthesia for cosmetic procedures.

The figures come from Health Insurance Review & Assessment Service data submitted Wednesday to Democratic Party lawmaker Seo Young-seok. The breakdown is starker at dermatology clinics: 15 of 1,546 dermatology practices, or 1 percent, employ an anesthesiologist. Among 1,231 plastic surgery clinics, 69, or 5.6 percent, do.

The supply gap has not narrowed as the sector has grown. The number of registered plastic surgery and dermatology clinics rose 11.8 percent, from 2,485 in 2021 to 2,777 this year. Over the same period, the share with an anesthesiologist on staff crept from 2.6 percent to 3 percent.

Meanwhile, sedation has become a routine upsell. At one plastic surgery clinic near Sinsa Station in southern Seoul on Wednesday, a staff member recommended sleep-inducing anesthesia — an additional 110,000 won ($81) per procedure — for a skin booster treatment, in which injectable substances are placed into the skin to improve its appearance.

"Because the treatment involves injections directly into the skin, many patients find it painful, so we usually put them under sleep-inducing anesthesia," the worker said. Asked whether an anesthesiologist was on staff, the clinic's consultation manager said: "The doctor does it. This is something that [a plastic surgeon] can handle alone."

That arrangement appears to be the norm. All 20 plastic surgery and dermatology clinics reviewed in southern Seoul advertised sleep-inducing anesthesia for cosmetic procedures, using pitches such as "Undergo a comfortable treatment without worrying about pain with sleep-inducing anesthesia!" None of the 20 had an anesthesiologist on staff. A representative of one clinic said, "The doctor performs procedures alone, […] but it is safe."

The clinical pharmacology argues otherwise. Drugs commonly used for sleep-inducing anesthesia, including propofol and midazolam, can suppress breathing at higher doses. Patients require monitoring throughout the procedure, with the depth of sedation adjusted as necessary. The Korean Society of Anesthesiologists states that sleep-inducing anesthesia should be administered by an anesthesia provider who can monitor the patient's condition.

"Sleep-inducing anesthesia is usually handled by a doctor alone. For major operations requiring general anesthesia, freelance anesthesiologists often do it as they move from hospital to hospital like grasshoppers," one anesthesiologist said. "Proper monitoring is difficult under this kind of system."

Outcome data reflect the risk. Of 50 deaths related to cosmetic procedures between 2016 and 2024 analyzed by the National Forensic Service, 23 — the largest category — involved anesthesia. Twenty-two of those 23 deaths occurred at clinics. In April, a woman went into cardiac arrest while undergoing a lifting procedure under sleep-inducing anesthesia at a plastic surgery clinic in Gwangju.

"The problem is that clinics recommend sleep-inducing anesthesia even for procedures where it isn't really necessary, leading patients to think of it as something minor," a doctor with experience working at cosmetic clinics said.

Two structural factors sustain the status quo. Clinics with only a small number of doctors struggle to justify employing a dedicated anesthesiologist, and current Korean medical law does not require one to administer sleep-inducing anesthesia. The true scale of sedation use is also invisible to regulators: cosmetic procedures fall outside national health insurance coverage and therefore never appear in insurance claims statistics.

Hong Sung-jin, a professor of anesthesiology and pain medicine at Bucheon St. Mary's Hospital, noted that sleep-inducing anesthesia is commonly used for procedures such as endoscopies — but added that without dedicated personnel monitoring the patient, responding immediately to unexpected situations is difficult, and he warned of the risk of cardiac arrest.

Legislative attention is now fixed on the gap. "The government should investigate the use of sleep-inducing anesthesia in cosmetic procedures and establish safety standards, including personnel other than the doctor performing the procedure to monitor patients, monitoring and emergency equipment and anesthesia records," Rep. Seo said.

If those standards materialize, the roughly 97 percent of Korean aesthetic clinics currently operating without an anesthesiologist on staff will face the sector's most consequential compliance decision since the sedation boom began.