On visiting China to investigate its burgeoning aesthetic industry, there is no better place to go than Shanghai. With a population over 24 million people it is the most populous city in the world. Sitting at the south edge of the mouth of the Yangtze river up against the eastern China coast, it has become a world financial center and has the world’s busiest container port. With so many people in an affluent part of China it should be no surprise that the aesthetic demands are high and businesses have emerged to meet it.
Thus enters the concept of the ‘Aesthetic Hospital’. More than just a marketing name these are comprehensive facilities that offer every available non-surgical and surgical aesthetic procedures. The gem of this concept in Shanghai would be the Shanghai Huamei Medical Cosmetology Hospital. Boasting four floors of aesthetic services, it offers a collection of services in one facility that is unlike anything seen in the U.S.
At the Shanghai Huamei Medical Cosmetology Hospital dedicated floors exist for all types of skin care and laser treatments, cosmetic dentistry, injectable therapies and plastic surgery. I have never seen such an assortment of lasers on the skin care floor for every treatment from skin rejuvenation and hair removal. The cosmetic dentistry floor provides teeth straightening (Angelalign = Invisilign), crowns and veneers and teeth whitening. (interestingly called American White Teeth Whitening)
The plastic surgery section has a number of plastic surgeon who mainly focus on just one procedure, doing many surgeries per day. The most common procedures performed include double eyelid surgery, augmentation rhinoplasty, chin and jawline reduction, breast augmentation and liposuction body contouring. Unlike in the U.S. where many such procedures are performed as an outpatient, in China these same patients often spend one to two days in the facility (hospital) getting all their required care. This is why there is a large section dedicated to patient rooms and nursing care just like in any other hospital. The facility even has its own pharmacy to supply all patient medication needs both inpatient as well as outpatient.
To illustrate the volume of non-surgical and surgical services provided, one only has to look at the display case of all the types of injectable fillers that are used.
Or, in talking to the plastic surgeon that only performs chin and jaw reductions, the numerous containers that contain all the portions of jaw bones removed just in the past year. (over 500 cases!)
Like so many things in China, everything is bigger and has proportionately more volume based on the population. The aesthetic industry is no exception. China has come along way in the past two decades and the creation of the Aesthetic Hospital concept is both unique and unparalleled to the rest of the world.
Located in East Asia, China is the world’s most populous country with a population close to 1.4 billion. It also has the world’s second largest land mass of just under 4 million square miles. It is composed of 22 provinces as well as has control over Hong Kong, Macau and essentially Taiwan. It has multiple large urban areas including Shanghai, Beijing, Guangzhou, Chongquip, Shenzhen, Tianjin and Hong Kong. Unlike the U.S which is bicoastal, China has only one long coast at its eastern side. A disproportionate amount of the population lies along this eastern region.
While China is a communist country with the central seat of power in Beijing, it looks and feels anything like that on the inside. While China may once have been an isolated country that was far behind the rest of the world, those days are long over. China is both modern and well organized and its tremendous wealth can be appreciated in its impressive infrastructure. Many areas of China are quite affluent and this can nowhere be more appreciated than in its two biggest cities, Shanghai and Beijing.
It should be no surprise that plastic surgery is both needed and thrives in a country with over a billion people. The amount of reconstructive surgery performed and is needed far outstrips the thousands of plastic surgeons that exist in the country. But it may surprise many as to how prevalent the aesthetic plastic surgery industry is. While many Chinese plastic surgeons perform cosmetic surgery, dedicated aesthetic hospitals exist. (a phenomenon not seen at this advanced level even in the U.S) These are not just a hospital name given to a small surgery center to sound impressive, they are true smaller hospitals with large square footages and full aesthetic services that boogle the mind of any U.S. plastic surgeon.
One example is the Huamei Aesthetic Hospital located in Nanjing China. Nanjing is an impressive Chinese city with a long rich history, having served as the capital city during many different dynasties. Known in the past as Nanking or Nankin it is located along the lower Yangtze river with a population of over 8 million people and the second largest city in the east China region.
The Huamei Aesthetic Hospital it is one of the most influential private hospitals in Jiangsu Province. It is also the East China Eye and Nose Plastic Surgery Research Institute. It is truly a hospital with four floors divided into multiple dedicated treatment areas. These include large treatment areas dedicated to skin rejuvenation, hair removal, hair transplantation, dentistry (teeth alignment, whitening, veneers), injectable Botox and filler treatments, non-invasive body contouring as well as plastic surgery with multiple operating rooms, recovery and hospital stay rooms.
The Huamei Aesthetic Hospital provides plastic surgery procedures that would be considered very typical for the Asian patient. These include double eyelid surgery, augmentation rhinoplasty, jawline reduction/reshaping, breast augmentation and liposuction. Most of the patients are younger and the aesthetic surgery would be considered more face and body reshaping rather than anti-aging surgery. (which reflects both how the Asian patient ages and recent cultural trends) The Chinese plastic surgeons who work there are employed by the hospital, are usually young, and often only perform one specific procedure.(e.g, rhinoplasty) This allows them to develop both expertise and efficiency in the surgery, which permits higher numbers of patients to be treated and, theoretically, with a lower rate of complications. The number of surgeries performed and the volume of patients treated per day is staggering by U.S. plastic surgery standards. (and probably anywhere else in the world)
The scope of proportions in China, for anything you can think of, far eclipses what happens here in the U.S. It is a fact of just sheer numbers. This is no different in aesthetic plastic surgery. The Huamei Aesthetic Hospital in Nanjing is an example of the Chinese applying a business approach to the concept of an elective service. They are experts at dealing with large numbers of people in an efficient manner.
In the same city is the Jiangsu Province Hospital. It was established in 1954 and is a 3A Grade Hospital in China. It is a comprehensive public hospital which integrated traditional Chinese and Western Medicine. It has 2,500 beds which are always filled. It sees an average of 20,000 outpatients per day. The Department of Plastic Surgery was established just twelve years ago and has grown impressively under the leadership of Professor Jinlong Huang. It has its own dedicated building with multiple floors. Each plastic surgeon there sees an average of 75 patients per day with over 100 reconstructive surgeries performed collectively per week. Unlike aesthetic surgery, reconstructive plastic surgery in China is mainly provided in public hospitals. These numbers are even more staggering as the cases of congenital birth defects, traumatic injuries and cancer reconstruction in China are many fold higher than in the U.S.
Far down to the south of the United States sits a country that looms large in plastic surgery. By the number of plastic surgery procedures performed to their history of technique innovations, Brazil is large in both land mass and in their pursuit of beauty.
Brazil is the fifth largest country in the world comprising over 3.2 million square miles. It is so large and occupies so much of South America that is comprises much of its interior and borders with every other South American country with the exception of Chile and Equador. With a population of almost 210 million people that speak almost exclusively Portuguese, it is the largest speaking Portuguese country in the world and theonly one in the Americas.
The role of Brazil in plastic surgery is significant around the world. The shape of the human body is a major beauty issue in a tropical country where the vast majority of the population lives by the Atlantic Ocean. (the heaviest concentration of the Brazilian population is in the southeastern section of the country) A flat abdomen, firm breasts and rounder shaped buttocks dominate what is important to women in this part of the world. That is so significant that the procedure and the term ‘Brazilian Butt Lift’ comes from the Brazilian desire for larger and firmer buttock shapes. Most forms of buttock augmentation that we know today, buttock implants, buttock fat injections and buttock lifts, have their origin from Brazilian plastic surgeons.
According to the Brazilian Society of Plastic Surgery, over 2.1 million plastic surgery procedures are performed per year (surgical and non-surgical) which represents about 10% of the world’s total. There are about 5,500 plastic surgeons in Brazil which makes up almost 15% of all plastic surgeons in the world. Body contouring procedures dominate with near 220,000 liposuction, 185,000 breast augmentation, 120,000 tummy tucks, 115,000 fat grafting and over 50,000 buttock augmentations/reshaping procedures performed every year.
Not to be outdone, men also have a lot of plastic surgery done as well. The Brazilian Society of Plastic Surgery estimates that a man gets some type of plastic surgery in Brazil every two minutes. That would mean roughly 250,000 Brazilian men or 12% of all plastic surgery patients in Brazil are done in males.
Ireland, technically the Republic of Ireland, is an enchanting island that is in the Atlantic ocean northwest of Great Britain. It covers over 32,000 square miles (or almost 85,000 square kilometers) and is one of the biggest islands in all of Europe. It’s history and politics divide the island into ‘mainland’ Ireland which is about 5/6s of the island and a smaller Northern Ireland which is part of the United Kingdom. It has a total population of about 6.5 million of which close to 2 million live in the much smaller Northern Ireland.
Despite its relatively small population, Ireland has five medical schools. (Dublin (2) , Cork, Limerick and Galway) Training in plastic surgery is done through the oversight of the Irish Association of Plastic Surgeons (IAPS) which is the voice of plastic surgery on the island. It is the only body of plastic surgeons that is recognized by the Royal College of Surgeons in Ireland and the national Medical Council. Its registry lists 32 accredited plastic surgeons with more than half located in Dublin. (Cork and Galway make up the rest) With prerequisite of 2 to 3 years of general surgery training, followed by one year of research, plastic surgery training then encompasses an additional six years.
In Ireland the formal name for a Plastic Surgeon is…Plastic, Reconstructive & Aesthetic Surgeon. As a result, aesthetic procedures are available all over the island at many major hospitals and clinics. Costs of various face and body cosmetic procedures is often only available on enquiry and few plastic surgeons openly advertise their prices and or even provide a general range on their websites. This may reflect adherence to the code of ethics from the Medical Council and endorsed by the Irish Association of Plastic Surgeons. Free consultations are common and costs of breast augmentation (4900 euro) and mini-facelift (3700 euro) are the few actual procedure prices that could be found.
Estonia is a country in the Baltic region of Northern Europe. It is bordered by the Gulf of Finland to its north, Russia to its East, Latvia to the South and the Baltic Sea to its West. It is one of the smallest countries in Europe with a population of around 1.3 million and a land mass of only 17,000 square miles. Its capital is Tallnin with a population of over 400,000. It has a long history of having been occupied by numerous countries but gained its independence from Russia in 1991.
It is considered a high income economy with an average per capita income of over $20,000. A balanced budget, very low public debt, a flat-rate income tax, free trade regime, competitive commercial banking sector, innovative e-commerce servies and even mobile-based services are all hallmarks of Estonia’s market economy. It is seen as a very wired country with the development of the software for the popular Skype having been done in Estonia.
There are just around 20 plastic surgeons in Estonia. Most of which are in he capital city of Tallnin or in Tartu, the location of the country’s major medical university and training center. All of the most common plastic surgery procedures are performed in the country and costs that are comparative to many other European countries. Plastic surgery consultations can be done from as low as 11 euros and up to 75 euros. Pricing for many procedures can easily be found such as breast augmentation (3900 to 4200 euros), rhinoplasty (2850 to 3700 euros), liposuction (250 to 500 euros per area), chin augmentation (1700 euros), full facelift (3900 euros), and tummy tuck with liposuction (3850 euros) to name a few.
Brazil is the largest country in South America and is the fifth largest country in the world. It occupies in land mass almost half of all of South America and has more land than that of the continental United States. (minus Alaska and Hawaii) It is unique in many ways from its Portugese language to being situated along the equator. Of the many things it is known for one of those is the large number of plastic surgery procedures performed within its borders.
While people feel that the U.S. is obsessed with body image and undergoing plastic surgery, it runs a distant second compared to the country of Brazil. According to statistics from the International Society of Aesthetic Plastic Surgery, Brazil has now surpassed the U.S. with the most cosmetic surgeries performed in the world. This is impressive given that the population of Brazil is less than that of the U.S. (203 million vs. 317 million) and with a far less GDP. (2.5 trillion vs 17 trillion) A total of over 1.5 million cosmetic surgeries were done in Brazil, a number that is well over 10% of all elective cosmetic surgeries done in the world. The statistics also show that Brazilian patients are more prone to having actual surgery while the U.S. patients partake of many more non-surgical procedures. (e.g., Botox, injectable fillers and lasers)
Such numbers raise the question as to why Brazil is so profoundly different when it comes to cosmetic surgery. The main reasons are two-fold and synergistic. First, Brazil has the highest number of plastic surgeons per capita than anywhere else in the world. While it struggles to find doctors to service even the most basic needs in remote and poor areas of its vast country, there is a disproportionate number of plastic surgeons. The other reason is that the economy of Brazil has grown considerably and, as such, disposable income has also increased. As part of its unique culture, women are particularly predisposed to spend their disposable resources on improving their appearance. It is so prevalent that having plastic surgery is a status symbol and is something of which to be proud.
Given the warmer weather, Brazil is well known for its body contouring procedures such as breast augmentation, breast reductions, liposuction and in particularly buttock enhancements. While breast augmentation is very popular in North America, buttock augmentation is more popular in South America. Brazil is the home and origin of the well known and highly performed Brazilian Butt Lift where fat harvested by liposuction is injected into the buttocks for enlargement.
Brazil’s most famous contribution to plastic surgery, however, is it own world famous plastic surgeon, Dr. Ivo Pitanguy. Practicing in the Brazilian capital of Rio de Janiero since the 1950s, he established his own clinic where be both operated on patients and trained surgeons. In a public hospital, he created his own ward where he has provided plastic surgery for free for decades. This epitomizes his philosophy that everyone has the right to look better physically.
Lebanon, formally known as the Lebanese Republic, is a small country located on the eastern Mediterranean sea. It is bordered by Syria in the north and east and Israel to the South. Because of its location at the crossroads between the Mediterranean and much of the Arab world, it has a long and rish history dating back to thousands of years B.C.. It is about 2/3s the size of the state of Connecticut (about 4,000 square miles) with a population of just over 4 million. The Lebanese population is surprising young with more than half being below the age of 25 and is one the most educated populations in the region. This may help to explain the tremendous popularity of plastic surgery in this historically war-torn country.
Some have written that Beirut, the centrally located capital along the coast is the Beverly Hills equivalent in Lebanon. Much of this impression comes from the short documentary film by a Lebanese-America woman entitled “Copy. Cut. Paste” which details what the filmaker describes as the Lebanese women’s unhealthy attraction to plastic surgery. Her observations were that many women of Beirut look very polished with their tattooed brows and thin bodies with large chests to their wrinkle-free skin and small noses. Much of this is explained to come from women in Lebanon competing to find a husband and build a family.”
As the film “Copy. Cut. Paste” reveals, Lebanon appears to have found a way to escape the political, social, and economic instability of two decades of war through plastic surgery. The combination of globalization, political and economical factors in a post-war country has helped drive the popularity of having plastic surgery. A surprising 1.5 million procedures are done annually in a country with just over 4 million people. The cost of plastic surgery in Lebanon is about one-fifth of that in the U.S..
El Salvador is the smallest country in Central America, oftened called the Tom Thumb of the Americas. With a population of just over 6 million in a land mass of around 8,000 square miles (the size of the state of Massachusetts), it is also the most densely populated country south of Mexico. It is situated on the Pacific Ocean with Guatemala to the west and Honduras to the north and east. Having switched to the US dollar as its currency in 2002, the average income is around $ 4,350.
What is the state of is plastic surgery in El Salvador? Talking to Dr. Gerardo Flores-Lima who has been in practice for six years in San Salvador, the country’s capital of over 500,000, the acceptance of plastic surgery is growing. In his six years of practice, he sees the limiting factor as affordability. With an annual average income that is less than the cost of many plastic surgery procedures in the United States, the prevalence of cosmetic surgery remains low but far from non-existant. The most popular procedures and their cost in El Salvador is liposuction ($1,500 per area), breast implants ($3,000) and rhinoplasty. ($3,000) Buttock augmentation is also sought after and is commonly done with fat injections although Dr. Flores’s preference is the insertion of buttock implants.
The Republic of Trinidad and Tobago lies in the southern Caribbean just off the coast of northeastern Venezuela. It has a population of 1.3 million people in a land mass of just under 2,000 square miles. The vast majority live on the larger Trinidad island. (96%) Unlike most of the English-speaking Caribbean, it is industrially strong with petroleum as its base. As a result, it is one of the wealthiest and most developed nations in the Caribbean with a high per capita annual income of over $20,000.
Board-certified plastic surgeon, Dr. Arno Schliech, has been in practice in Port-Of-Spain for the past five years. While of German birth, he is married to a Trinidad physician which explains his island presence and familiarity with its cultures and people. When it comes to plastic surgery, the most common procedures in the Caribbean in general and Trinidad in particular is body contouring. The climate and the clothes play a big role. The most popular body contouring procedures are liposuction,, tummy tucks and breast augmentation and breast reduction. The big trend now is gluteal reshaping with fat transfer (aka Brazilian butt lift). This is a great procedure to do in Trinidad and the Caribbean as women there are already curvy, have some fat to harvest and the results are very satisfactory, which makes the procedure very rewarding to do.
Most of patients seeking plastic surgery come from the islands although medical tourism from the US, Canada and the UK is growing. Amongst these patients, 99% have dark skin – Afro-Caribbean, dark East Indians, Creole etc. Rarely is anybody less than a Fitzpatrick V skin classification. As a result, surgical incisions are a big patient concern.While most incisions heal well eventually, more effort is put into various scar treatments to optimize their final appearance.
Facial aging occurs differently on the islands. Dark skinned people do age differently and much slower, at least in the face. The bone structure is also different. Most facelift and periorbital rejuvenation patients are predominantly medical tourists from the US or Canada. The island population gets to this stage probably fifteen or more years later than Caucasians and then often have a reduced interest in this kind of surgery in favor of body contouring.
Gynecomastia in men is a frequent problem, particularly in East Indians. Whether it actually occurs more frequently or is a function of Caribbean men spending a considerable amount of time bare chested is uncertain. But Dr. Schleich states that he operated on more gynecomastias in his first year in Trinidad than during his previous career. Female breast reduction is also very common but all island governments and health systems consider it as a cosmetic procedure and don’t pay for it.
The most difficult aestheic problem in Trinidad and in the islands in general is the high rate of permanent facial disfigurement resulting from acne scarring, The dark skin pigments limits the traditional use of treatments such as laser, pulsed light and dermabrasion. So effective acne scar treatments are lacking. Conversely the darker and thicker Caribbean skin makes cellulite a very rare problem.
Private hospital services in Trinidad are relatively expensive compared to the average per capita income of the population, but mostly quite a bit less than in the U.S. Some of typical procedure costs for aesthetic plastic siurgery are breast augmentation ($5,000), rhinoplasty ($6,500) and liposuction. ($5,500)
Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.