LONDON, United Kingdom — Say the words “plastic surgery” and the full pouts and Barbie-like proportions endemic to Hollywood or Miami probably spring to mind. But as anyone who has spent an afternoon in Seoul, South Korea, can attest, both the unusually high occurrence of bandaged locals and the exaggerated cuteness of the ‘aegyo’ aesthetic are clear indications of a society more deeply entangled with surgical improvement than anywhere in America.

Compelling data now backs this up. The International Society of Aesthetic Plastic Surgeons (ISAPS) last week published the results of their annual Global Aesthetic Survey for 2016. Their most extensive report to date, it shows a worldwide increase of 9 percent in surgical and non-surgical cosmetic procedures over the last year, with a noticeable 45 percent rise in labiaplasty and a 22 percent rise in buttock lifts.

While the top five countries in the ranking — America, Brazil, Japan, Italy and Mexico — are responsible for almost half of all identified surgeries globally, this doesn’t necessarily mean that surgery is most widespread in these nations. The leaderboard actually shifts when you calculate per-capita figures (BoF used World Bank population data).

The United States, for instance, has the greatest number of procedures overall at 4.2 million but this amounts to 13 people per thousand, which is significantly less than other cosmetic surgery hotspots around the world.

In South Korea, too many surgeons chose not to participate in the latest ISAPS audit for the country to be included, but using figures released last year, about 20 people per thousand are having a procedure in the country, by far the highest proportion on earth. Taiwan and Belgium are not far behind with 17 people per thousand, followed by Lebanon and Italy at 16.

Colombia and Brazil are currently on a rate of around 12 per thousand — a remarkably high number given their relatively large populations and the fact that millions of people in both countries live below the poverty line. This boon in popularity has not been without consequence however, as rising demand in the South American nations has attracted medical practitioners without the necessary training, raising the risk of botched jobs and disfigurements. Emerging cosmetic surgery hubs including India, Thailand and Turkey, where regulation is lacking, also face the same issue.

According to intelligence provider Research and Markets, the global cosmetic surgery market is currently worth over $20 billion and is set to rise to over $27 billion by 2019. “The industry is growing at an enormous rate,” says ISAPS president Renato Saltz. “We are in 103 countries, but all we can do as responsible leaders is make sure the training is adequate and that the accreditation process is as strong as possible and pray and hope the consumer does their homework before selecting surgeons.”

Some high per-capita figures are undoubtedly weighted towards countries with relatively small populations and high rates of medical tourism, but it is interesting to note that certain cities now dominate the cosmetic improvement world beyond Europe and North America — Seoul and Taipei; Medellin and Rio de Janeiro; Beirut and Tehran among them.

“It is mainly culture that makes some countries more susceptible to surgery,” says Saltz. “In certain cultures, people are more concerned with how they look than others. France and Italy have always been leaders in beauty in Europe and their plastic surgery figures are high. Or in Colombia, television is hugely popular and almost exclusively shows beautiful people, so no wonder people are more susceptible.

“I’d say proximity to the ocean is another factor — Rio [de Janeiro, Brazil] has been a leader in body contouring because people are on the beach all day. The reasons are diverse. Here in Utah, where I live, the state is dominated by the Mormon church and [some] women have had six children by the age of 30. Their bodies are severely damaged, hence all the tummy tucks.”

Whatever their motivations, it is clear that clients seeking surgery in newer hubs across Asia, the Middle East and Latin America are prompting the exploration of new beauty ideals and with them, new cosmetic surgery business fortunes.

South Korea and Taiwan

Earlier this year, K-pop girl group Six Bomb released a single called ‘Becoming Prettier’, an uninhibited celebration of plastic surgery, specifically the rumoured $90,000 overhaul the band members personally underwent. And while Six Bomb’s surgery themed music video made headlines worldwide, it also leapt up the charts in many parts of Asia.

Seoul wields an unusual degree of soft power over the rest of the continent, and the surgically enhanced look of certain K-Pop stars has had a ripple effect across Asia. As a result, the thousands of plastic surgery clinics in the South Korean capital now dedicate an estimated third of their operations to Chinese and South-East Asian clients.

This means big business, with the Korean medical tourism industry currently worth around $500 million annually, according to estimates from the Korea Tourism Organization, an agency that is hoping to attract a million medical tourists a year by 2020. But South Korea’s current stand-off with Beijing over the Thaad missile crisis resulting in restrictions for some Chinese tour groups could have an impact on future revenues.

It is a similar story in Taiwan, where, of the 388,000 operations performed last year, up to a third are estimated to have been for mainland Chinese tourists who now cross the Straits individually and in groups for high-quality surgery that is often more affordable than in China.

Many K-pop stars have had work done and it has been essential to their careers. So people think, ‘I’ll be more competitive if I have it too.’

Double-eyelid surgery, or blepharoplasty, accounts for nearly half of all surgical operations in South Korea and Taiwan. Even a South Korean president — Roh Moo-Hyun — famously had the procedure while in office a decade ago. It is so ubiquitous in certain parts of both countries that teenagers receive it as an 18th birthday present.

Enthusiasts of the procedure dispute the claim that blepharoplasty perpetuates a Eurocentric look, and that it has turned a physical characteristic of East Asians into a ‘problem’ that many feel the need to ‘solve’. It is rather, they say, a benign update of beauty ideals for a new generation.

It is difficult to pinpoint a single reason why surgery has become so popular in South Korea and Taiwan, although a number of theories abound. “I think the high-speed industrialisation of the 1970s and ‘80s that took us from a poor country to the eleventh largest economy in the world had a big impact,” says Haesoon Jung, the Korean-born editor of fashion and tech consultancy Styleintelligence. “The nation realised that change and improvement was a good thing, and something like plastic surgery could bring you a better future with good job prospects or a more attractive spouse.”

Another consideration could be the relatively poor gender equality ratings in South Korea, or simply the fact that Seoul has fashioned itself as the Hollywood of Asia, and is therefore mimicking the famously aesthetic-driven values of Los Angeles, but in overdrive. “Of course celebrity culture has influenced ordinary people to have plastic surgery,” says Jung. “Many K-pop stars have had work done and it has been essential to their careers. So people think, ‘I’ll be more competitive if I have it too.’”

Saltz believes the future of the plastic surgery business lies in East Asia — both in terms of innovation and popularity. He names China in particular, a country that, like South Korea, did not participate in the ISAPS survey. “Asia will dominate the numbers for many years to come,” he says. “China has fantastic reconstructive surgeries and excellent training programs, as does South Korea. The US still has a huge market of course, so I foresee a future with East Asia and America steering the entire industry.”

Brazil and Colombia

“In Latin America, the powerful class are the beautiful class,” says Miguel Soffia, a documentary filmmaker who has spent years studying plastic surgery trends across South America. “I believe underneath it all, we still want to look European because of the conquistadors, but with this Latin ideal of voluptuous beauty. And often surgery is the only way.”

Brazilians had 2.5 million surgical procedures last year — 11 percent of the total worldwide share and second only to the US. The majority of surgical requests are actually focused on body sculpting: improvement to the breasts, abdomen and buttocks. “One of the biggest trends worldwide this year is for Brazilian buttocks,” says Saltz. “It is a trend entirely started in Latin America and for a while it was contained there. But it’s fascinating to see how widely it has been exported to the rest of the world.”

Colombia, meanwhile, is a country known for its high-quality health service. Oxford Business Group estimates medical tourism was worth $216 million to the economy in 2014 while ISAPS figures show that half a million official cosmetic treatments took place in Colombia last year, of which Soffia estimates around 75,000 were performed on tourists.

Across Latin America, finding a plastic surgeon is as easy as finding a hairdresser.

However, a loophole in Colombian law has allowed certain medical practitioners to exploit the system, bypassing the necessary five years of training by earning a six-month qualification in neighbouring Brazil and converting it for Colombian use. As a result, there has been a high number of disabilities, and even deaths, caused by rogue “surgeons” performing operations they are unqualified and untrained for.

“Across Latin America, finding a plastic surgeon is as easy as finding a hairdresser,” says Soffia. “Women are desperate and will choose the cheapest option because they have bought into these unreal expectations of Latin beauty that are foisted upon them. And in Colombia, Venezuela and Brazil in particular, they believe that the only way to be a valued member of society is to look beautiful. It is going to take us a while to change the culture, but governments urgently need to address the regulation problems in all three countries.”

Saltz, meanwhile, is more optimistic about the Colombian plastic surgery industry. “I have personally been very impressed by the surgeons I have met in Colombia and the trends the country is leading in,” he says. “They have outstanding surgeons but, yes, also bad guys. They do urgently need a general centralised system of licensing and patients need to become more aware when they are booking a surgery.”

Lebanon and Iran

According to official figures from the Iranian Association of Cosmetic and Plastic Surgeons, only 40,000 cosmetic surgeries take place in Iran each year, but ISAPS believe the actual number is more than triple that, at 151,000 — or nine people per thousand. Even that may still be conservative, as thousands of non-specialist, undocumented surgeons in Tehran cash in on the sharp increase in demand for invasive treatments.

“I don’t think the statistics are particularly surprising,” says Iranian plastic surgeon Ali Asghar Shirazi. “Iran is one of the most populated countries in Middle East and it is a relatively rich country… Here in Iran, we have many patients from neighbours like Iraq, Bahrain, UAE, Azerbaijan and Armenia.”

It is nonetheless interesting that in a country ostensibly governed by conservative morals that quite so much emphasis is placed on physical beauty. According to ISAPS, 12,100 rhinoplasties took place last year in Iran — even more than in Lebanon.

Until recently, however, it was Lebanon that was known as the plastic surgery mecca of the Middle East, with surgically enhanced beauty becoming the norm in the bars and restaurants of Beirut and people from all over the Gulf and North Africa flocking to its shores for treatment.

In Lebanon too, there is an unusually high proportion of rhinoplasties in both men and women, with people still flying in for a nose job that, on average, is half the cost of one in Europe or North America.

Lebanese television had a big impact... It introduced a new wave of young, pretty newsreaders who were different from the old school.

“The shape of the nose has long been seen as ‘problematic’ by some in our region,” says Jamila Halfichi, the fashion and lifestyle editor at pan-Arab daily newspaper Asharq Alawsat. “We are not all ‘blessed’ with small and straight noses that fit the idea of Western beauty standards which have been peddled for so long across the Middle East.”

“I think Lebanese television had a big impact,” Halfichi adds. “When MBC [The Middle East Broadcasting Center] launched a few decades ago, it introduced a new wave of young, pretty broadcasters and newsreaders who were different from the old school. Men were mesmerised and smitten and women wanted to look like them as they were somehow more familiar and accessible than film stars.”

Today, Lebanon's First National Bank even offers loans specifically for cosmetic surgery and while the Lebanese appetite for cosmetic improvement shows no sign of abating, a proliferation of newly qualified surgeons in Iran, Turkey and Dubai have eaten into its medical tourism market, with an estimated 30 percent decrease reported at some of Beirut’s treatment centres.

While there is no denying that outdated notions of Eurocentric beauty have played their part in the plastic surgery business boom across many parts of the world, Saltz sees change afoot.

“I do believe that there’s been a globalisation of beauty. The cultural divide used to be very strong but the internet has played a role in homogenising that,” he says. “These days we see an amalgamation of European and Asian features, with South American bodies.”

Nevertheless, the fact that surgically enhanced beauty could one day become the most acceptable face of international womanhood is something that should give us all pause for thought.

“Ultimately, it comes down to the older generation wanting to hold onto their youth, while the young are into Botox and fillers to emulate the likes of the Kardashian sisters,” sighs Halfichi.

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