Cultural Aesthetic Considerations

Babak Farzaneh, MD is a fellowship-trained cosmetic surgeon in private practice in Chino, CA.

The world we live in continues to get smaller every day, thanks to the dense networks of telecommunications and vast infrastructures of airports and highways that connect us to one another. Today's age is one of unparalleled awareness of other nations and ways of being—a time when international travel is within the financial grasp of more of the world's population than ever before, and a time when the human body is extraordinarily modifiable. And the implications for cosmetic surgery have never been more immense.

As should be no surprise to the readers of Modern Aesthetics, one of the United States' most significant exports is entertainment, and with that entertainment comes a particular image of beauty. However, as Scottish philosopher David Hume reminds us, “Beauty is no quality in things themselves: It exists merely in the mind which contemplates them; and each mind perceives a different beauty.” That is, without human perception and analysis, there can be no beauty. For that reason, the vague and contestable notion of beauty is often shaped in a profound way by various cultural factors.

One of the privileges of my job has been the ability to work with a number of international clients, and as such, I have developed a better awareness of how culture plays a factor in determining the physical traits that others seek to alter.

WORLDWIDE PROCEDURES

First, a little background on the global context is important. As per-capita income rises around the world, and as a number of countries have become more developed, the global demand for cosmetic surgery has risen sharply. According to the most recent figures published by the International Society for Aesthetic Plastic Surgeons, the US led the world in the number of surgical and non-surgical cosmetic procedures performed in 2011, but represented only 21.1 percent of the total worldwide. In other words, nearly 80 percent of all of the 14.7 million cosmetic procedures performed in 2011 occurred outside of the US. Reuters additionally reports that global demand for cosmetic surgery grew 10 percent between 2011 and 2012, with a similar increase projected for 2013.

We hear a lot of stories in the news about “medical tourism,” which has become its own buzzword. Especially over the last decade, there have been more reports of patients electing to have their procedures performed in countries where cosmetic surgery is experiencing a renaissance, such as South Korea and India. The more affordable cost of having a face lift or tummy tuck done outside of the US is also appealing to many.

We should bear in mind that medical tourism runs both ways. In particular, the US is attractive to my international patients because it is perceived as the very locus of Western beauty. Many of the world's medical tourists choose to have their procedures performed by Western doctors used to catering to a clientele of Westerners. Others choose to become medical tourists for reasons of safety and are attracted to the US due to our nation's high standard of patient care and assurance of patient rights.

As Eugenia Kaw once noted in her landmark and widely referenced article, “Medicalization of Racial Features,” the pervasiveness of Western media throughout the world might not create a single definition of beauty shared by all races, creeds, and cultures, but it has affected an international idea of what constitutes neutrality. Writing for Medical Anthropology Quarterly, Kaw wrote that, “While the features that white women primarily seek to alter through cosmetic surgery (i.e., the breasts, fatty areas of the body, and facial wrinkles) do not correspond to conventional markers of racial identity, those features that Asian-American women primarily seek to alter (i.e., ‘small, narrow' eyes and a ‘flat' nose) do correspond to such markers.”

While Kaw's article focused on Asian-Americans, her pattern has held true for the most popular procedures undertaken by Asians annually both here and abroad—both blepharoplasty and rhinoplasty are consistently at the top of the list. However, Kaw's insights are highly applicable to a number of other international patients. One of the most common concerns my international patients share with me is a desire to remove the qualities that signify them as being a racial “other.” For better or for worse, an international market for entertainment has produced a standard of beauty that—even where it is not overtly Western—blends many different races and ethnicities together in a way that can be somewhat homogenized. As a result, patients from the Arab world often desire less-prominent noses, and it is common for many South American patients to seek breast reductions.

I should note, however, that the demand for cosmetic surgery among international patients—even in cases where they might wish to eliminate identifiable racial traits—does not reflect a self-conscious desire to become Caucasian. Even in the case of the extremely popular double-eyelid blepharoplasty, there are many Asians who are naturally born with double eyelids, making it questionable whether this is indeed a “white” trait that they are attempting to emulate. I would argue that it's more accurate to say these patients feel traditionally racial traits mark them as being from a particular place or background. As such, patients see them as barriers to defining themselves primarily as individuals before they are defined as members of a particular group.

THE “IDEAL” HUMAN FORM

While a variety of literature has been written on cosmetic surgery as a means of erasing links to race and culture, what has been less-explored is the ability of cosmetic surgery to enhance these bonds. Time and time again, I encounter clients from Mexico and South America who arrive to their first consultation because they are strongly considering breast augmentation or enhancement of the buttocks. Within Latin America, there is often a strong cultural message for women to be bold, beautiful, and voluptuous. For that reason, a Hispanic woman with smaller breasts and a less-prominent bottom may come to wish that she were more “marked” by outward identifiers of her race or culture. Truly, there is no “one size fits all” with the ideal human form.

In other cases, cultural expectations and lifestyle differences tend to create different demands for procedures based purely on pragmatic grounds. In Italy, for example, much of the culture revolves around fashion and clothing. More than once, I have heard of Italian women wanting their knees to be given a more youthful look so that they may feel more comfortable in shorter summer dresses. Typically, these “knee lift” procedures involve trimming the sagging, excess skin around the knee and combining the procedure with liposuction. Alternately, Thermage and Titan lasers utilize radio waves and near IR light, respectively, in an attempt to tighten the skin above the knee for a non-surgical approach.

MULTICULTURAL VISION

Having traveled around the world and as a student of the human form, I have a vision of beauty that is truly multiracial and multicultural. In consultations, I feel it is important to help patients establish options that will allow them to retain a natural look—I never attempt to transform a patient into someone new, but to reshape and modify the body they were born with. As such, I feel that race and culture are elements of a person's identity to be celebrated and cherished rather than erased. If a patient desires a procedure that will make them unrecognizable when they look in the mirror, I don't feel comfortable performing it.

To this end, it's important to note that the culture and degree of acceptance that surrounds plastic surgery itself is highly variable. As Americans, we tend to think of ourselves as highly accepting and permissive when it comes to many social issues, including cosmetic surgery. However, in countries like China and South Korea, cosmetic surgery has exploded as a commodity and as a socially accepted way of improving one's class and career opportunities. By many estimates, approximately 20 percent of all South Korean women between the ages of 16 and 45 have had at least one procedure performed.

The reality of working with international patients is that many medical tourists will often present a veritable shopping list of work they'd like undertaken during their consultation, much of which could jeopardize their health or lead to complications that must carefully be weighed and considered. As I often tell my patients, elective surgery is still surgery. Pain and recovery time must be factored into a patient's decision to have the procedure performed, but it is too often overlooked.

In support of this, I point to the massive rise of orthognathic surgery—commonly referred to as V-line or mandibular angle reduction surgery—as a way to reshape the jawline from a rounded figure to a more pointed shape. In order to accomplish the procedure, the jaw is sawed through, repositioned, and set with screws and a titanium plate. Patients typically need a week to recover from the surgery, and it carries a risk of bleeding, hematoma, infection, and palsy of the facial nerves. While the procedure is typically only undertaken in the US by maxillofacial surgeons needing to correct a medical problem, such as reoccurring jaw pain or difficulty swallowing, its popularity has exploded in South Korea as a purely cosmetic procedure.

In cases where patients come from a consumer culture that may even exceed our own, it is vitally important to educate the patient that cosmetic surgery is not a decision to be taken lightly and that, within the US, our primary concern is their health. We aren't technicians delivering a product, but doctors responsible for exercising professional judgment and ensuring that our patients maximize their chances of a safe and healthy recovery.

INTERIOR BEAUTY

The famous psychologist Dr. Elisabeth Kubler-Ross once said, “People are like stained glass windows. They sparkle and shine when the sun is out, but when the darkness sets in, their true beauty is revealed only if there is a light from within.” I believe that the reason we cosmetic surgeons do what we do is to give people that inner light—to allow them to redefine themselves as the people they wish to be.

It helps to keep in mind that when patients come to our consultations, they are a complex patchwork of social norms, ethnic backgrounds, and racial constructs—all factors that can be extraordinarily powerful in shaping a person's identity. Speaking personally, understanding those cultural patterns has allowed me to gain a deeper insight into the psychology of my patients and a tremendous insight into the commonalities of beauty all around the world.