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The Right to Beauty and the Development of Plastic Surgery in Brazil and South Korea

A rendering of Homa, the mythological Persian bird that never stops flying, caught my eye. The line to pick up boarding passes and drop off checked luggage for Iran Air was a train of luxury shopping bags, headscarves, and nasal casts. I had landed in Dubai International Airport, which contained a fascinating mix of people from all over the world. It was my first trip to the city, a 30-minute flight from Doha, Qatar where I was based working as a teacher at Weil Cornell Medical College. It was the only flight I have experienced where we started the descent at almost the exact moment we reached cruising altitude.

I have long been fascinated with Iranian culture and history. It may be because my uncle through marriage is Iranian. But despite this fact, my exposure to Iranian culture was shallow. I remember my uncle’s mother visiting them in Lexington, Kentucky in the nineties. From Ahvaz, Iran, she was a very short woman in a headscarf who would spend all day stirring a pot of rice and the evenings smoking hookah under a tent in their backyard. I do not remember eating her rice, or any Persian food for that matter. Iranian culture seemed mentally so comfortable I never processed the differences from American culture. It also seemed physically inaccessible. I would be unable to travel to Iran during my time in Doha because it is potentially dangerous to travel there as an American.

I understood why many Iranians – especially women – would travel to Dubai to shop and drink. I was curious, however, as to why so many women had casts on their nose. I correctly assumed they had undergone rhinoplasty surgery. Still, the sheer number as a percent of passengers boarding flights with Iran Air was shocking. I would later learn that Iran is a world capital for facial plastic surgery, specifically rhinoplasty. I would then learn from my wife, who is Iranian American, that rhinoplasty is an incredibly common procedure undergone by Iranians in the United States as well.

We in the United States naturally have a Western-focused view of plastic surgery, assuming the high quality of our trained surgeons, the advanced technology we possess, and our collective wealth – thereby allowing many to afford plastic surgery procedures – would place the United States and Europe in an echelon above the rest of the world. That certainly was the case for a period. However, the history of plastic surgery long precedes the founding of the United States and the Western European nation-states. More recently, centers for plastic surgery outside of the United States and Western Europe have developed. Americans have influenced these centers. They, in turn, will influence us. The essay below seeks to provide some information on and context to two of these global centers, Brazil and South Korea. I would have liked to provide more information about the development of plastic surgery in Iran. However, the English-language literature available is limited.

Brazil

“Oh it’s part of daily life now. It’s easier, safer – techniques have improved. And everyone’s doing it. My secretary is having plástica because something is bothering her. This is cool. I have the flu so I take medicine. I have a falling breast, so I have plástica. To feel better, to work better, to be in a better mood.” – Brazilian plastic surgery patient quoted from the book Pretty Modern: Beauty, Sex, and Plastic Surgery in Brazil by Alexander Edmonds

Many international visitors visited my fellowship director Andrew Jacono in New York City while I was training with him through the American Academy of Facial Plastic and Reconstructive Surgery. By far the best represented nationality was Brazil. We would routinely have anywhere between one and five Brazilians visiting for a day-or-two to ask questions of a widely regarded master of facial plastic surgery. In turn, I learned a great deal about how these surgeons practiced. For example, I learned that most practice in the relatively wealthy southeastern area of the country where the cities of Sao Paolo and Rio de Janeiro are located. I also learned that Brazilian national pride as a “melting pot” of individuals of African and European descent deeply influences the aesthetic norms there. We exchanged ideas and techniques. We showed them some of the most advanced techniques in facial plastic surgery. But we also learned from them. It was a window into what is a robust academic and cultural center for plastic surgery.

The International Society for Aesthetic Plastic Surgery (ISAPS) statistics on practice patterns around the world in 2020 identified 1.3 million plastic surgery procedures performed in Brazil in 2020, compared with 1.5 million performed in the United States. That makes the per capita rate of plastic surgery in Brazil (1 procedure per 163 individuals) higher than that of the United States (1 procedure per 220 individuals). The most popular surgical procedures performed in Brazil in 2020 were, in order, liposuction, breast augmentation, eyelid surgery, abdominoplasty (“tummy tuck”), and breast lift. The most popular surgical procedures performed in the United States in 2020 matched those in Brazil.

Most attribute the foundation of plastic surgery in Brazil to one man, Ivo Pitanguy. Dr. Pitanguy, the world-famous plastic surgeon from Brazil, argued for the “right to beauty” for all, rich and poor, through plastic surgery. Furthermore, he argued that plastic surgery is a vehicle for social and economic advancement as well as a way of improving overall health. Dr. Pitanguy is lionized for his role in the professional organization and cultural spread of plastic surgery in Brazil. My sister-in-law, a pediatric ophthalmologist, is from Brazil. One of the first questions she asked me when I told her I am a facial plastic surgeon was whether I knew who Ivo Pitanguy is. Not only did I know who Ivo Pitanguy is, I use one of his anatomical markers to identify the approximate course of a branch of the facial nerve when I perform an extended deep plane facelift.

But while Dr. Pitanguy planted the seed, no individual is solely responsible for the flowering of popularity of plastic surgery in Brazil. As Alexander Edmonds explains in Pretty Modern: Beauty, Sex, and Plastic Surgery in Brazil, not only the medical community but also the media and national government contributed. For example, the democratically elected president of Brazil in the 1950s was a supporter of Ivo Pitanguy and his mission. This mission gained broad public support after Dr. Pitanguy and his residents treated hundreds of children after a terrible indoor circus fire broke out in Rio de Janeiro. As a result, the president helped fund the establishment of the first teaching hospital for plastic surgery at Santa Casa, an old Catholic charity hospital in the city.

The Unified Health System (UHS) was established in Brazil in 1988, shortly after the end of the military dictatorship and shortly before the first democratic elections in many decades. The UHS expanded the public health system but did not nationalize all hospitals and providers. It did, however, improve funding for residency programs, including in plastic surgery. This provided new monetary support for the program Ivo Pitanguy started at Santa Casa, which has treated over 44,000 patients and trained almost 450 physicians from its opening to the early 2000s.

Aesthetic and reconstructive surgery procedures are offered at a significant discount in the public hospitals, where resident and attending plastic surgeons care for and operate on patients. This has greatly expanded the access of plastic surgery to the public. One major reason aesthetic plastic surgery procedures are effectively subsidized in Brazil is because the distinction between reconstructive and aesthetic plastic surgery is blurred in Brazil, largely due to the influence of Dr. Pitanguy. As a result, plastic surgery residents gain extensive experience, which they utilize both in the public hospitals and private clinics, which is where most plastic surgery performed in Brazil. And while the healthcare system has fewer resources than that of the United States, Canada, and Europe, foreign physicians visit Brazil to train and observe in droves. This has improved the reputation of plastic surgery in Brazil internationally.

The media in Brazil also contributes to the popularity of plastic surgery. One dominant media conglomerate, Globo, promotes plastic surgery and celebrates the television and movie stars who are more open – and often celebratory – about the plastic surgery they have undergone. Popular telenovelas as well as magazines such as Plastica & Beleza and Plastica & Corpo that focus on plastic surgery are read widely. This reflects the high value Brazilian society places on individual beauty and health.

South Korea

“This [Korea] is indeed a plastic surgeon’s paradise.” – Dr. David Ralph Millard quoted from the book Reconstructing Bodies: Biomedicine, Health, and Nation-Building in South Korea Since 1945 by John Dimoia

Commonly referred to as the “Republic of Plastic Surgery,” South Korea is home to the largest number of cosmetic plastic surgery procedures performed and the largest number of cosmetic plastic surgeons per capita in the world. Most South Korean plastic surgery patients are female, which reflects a strict cultural expectation that women maintain a youthful appearance when in public life. Possibly because of this cultural expectation, South Koreans begin undergoing cosmetic plastic surgery at a relatively young age. A Gallup Korea poll from 2015 found that one-third of women ages 19 to 29 have undergone plastic surgery in South Korea. According to the NPR reporter Elise Hu in her book Flawless: Lessons in Looks and Culture from the K-Beauty Capital, high school graduates are commonly given gift certificates for cosmetic surgery by their parents and grandparents. The three most common procedures chosen by patients are double eyelid (blepharoplasty) surgery followed by rhinoplasty then jaw contouring surgery, otherwise known as V-line surgery. More specifically, the New Yorker reporter Patricia Marx describes the Bagel Girl look, short for “baby-faced and glamorous,” as being popular among South Koreans as of 2015. In addition to V-line surgery, double eyelid surgery with epicanthoplasty (will be discussed below), and rhinoplasty, fat grafting to the lower eyelids is considered to contribute to this look. Regardless of the name given to this look, the history of cosmetic plastic surgery in South Korea and possibly the future of cosmetic plastic surgery worldwide can be found in the three most common cosmetic plastic surgery procedures pursued.

The origin story of cosmetic plastic surgery in South Korean, according to most Western authors, begins with an American named David Ralph Millard. Dr. Millard was the plastic surgeon for the United States Marines in South Korea. He trained with the famous plastic surgeon Dr. Harold Gillies during World War II. He remained in South Korea after the armistice in 1953 and continued to practice as a plastic surgeon, performing both cosmetic and reconstructive surgery on American troops and South Koreans. The two procedures he performed most frequently on South Korean patients were double eyelid surgery – which created an extra fold in the upper eyelids – and rhinoplasty meant to increase the projection of the nose. Patients included South Korean sex workers trying to better attract American troops and South Korean women who married Americans and felt plastic surgery would ease their transition to life in the United States. Like Ivo Pitanguy, Dr. Millard believed he was empowering those he treated by transforming their character. He also believed he was a pioneer in the techniques he utilized.

The professor John P. DiMoia argues against this origin story in his book Reconstructing Bodies: Biomedicine, Health, and Nation-Building in South Korea Since 1945. Mr. Dimoia writes that the story of Dr. Millard, while important, is incomplete. For example, the technique Dr. Millard employed for double eyelid surgery was only one of over thirty techniques developed since the late 1800s. In fact, according to Elise Hu, the first reported double eyelid surgery in the literature was published by the Japanese ophthalmologist and surgeon Kotaro Mikamo in 1896. South Korean surgeons more often cited the techniques of Japanese plastic surgeons from the late 1800s to the 1920s in their publications and teaching, because Japan was a regional center for plastic surgery at the time.

The professionalization of the field of plastic surgery started with the foundation of the Department of Plastic Surgery at Yonsei University in 1961. Residents were taught starting in 1964. However, it was not until 1973 that plastic surgery was officially recognized as a subspeciality in South Korea. Private plastic surgery clinics providing cosmetic services would start to predominate reconstructive surgery programs in the 1980s and 1990s after healthcare reforms largely nationalized the healthcare system. Physician-reported difficulties getting paid by the South Korean government for medical services pushed plastic surgeons to break from large hospitals and establish their own private cosmetic plastic surgery clinics in the Gagnam district in Seoul.

Another impetus for the movement of plastic surgeons to cosmetic procedures was the fact that the government supported the development of the industry (like Brazil), starting by temporarily subsidizing cosmetic surgery after the financial crisis of the late 1990s. According to Elise Hu, in addition to creating tax breaks for cosmetic plastic surgery domestically, the South Korean government started the Korea Culture and Content Agency to promote popular Korean culture worldwide, referred to as Hallyu, which includes cosmetic plastic surgery. As a result of the government’s effort, the number of medical tourism patients increased almost tenfold, from 60,000 in 2009 to almost 500,000 in 2019. Most tourists come from China, which accounts for 40% of all plastic surgery procedures in South Korea. Japan, the United States, Thailand, and Vietnam round out the top visitor countries. This medical tourism has spread the influence of South Korean aesthetic plastic surgery procedures and aesthetics around the world, including the United States. For example, I once met a Caucasian patient from the United States who had travelled to South Korea for V-line surgery. This individual explained that they desired a narrower, more refined jawline. They were very satisfied with their results. However, they were told by the South Korean surgeon that they would likely require a facelift earlier than normal due to the procedure. This individual returned to the United States and sought a facelift within a few years of undergoing V-line surgery.

The geographic center of plastic surgery in South Korea, called the Improvement Quarter/Beauty Belt/Plastic Surgery Street in the Apgujeong and Sinsa wards of the Gagnam district, is significantly smaller than that of Brazil. The “Beverly Hills of Seoul” got its start as a “new money” neighborhood on the outskirts of Seoul in the 1980s where land was less expensive than in the city center. It is home to over four hundred plastic surgery clinics per square mile and over seven hundred clinics total as of 2007.

This concentration of surgeons and the number of cosmetic plastic surgery procedures performed in South Korea has resulted in a great deal of innovation in the field, which patients around the world are only just starting to benefit from. For example, an additional focus of South Korean surgical innovation from the 1960s to the present has involved not simply the creation of double eyelids but also the removal of an extra fold of skin in the medial eye near the nose that is present in some South Koreans, called the epicanthal fold. Mr. Dimoia and Ms. Hu argue that there is a misconception that double eyelid surgery and epicanthoplasty surgery were meant to make South Koreans look more Western. In fact, double eyelid surgery and the epicanthoplasty reflect an independently developed, regional Asian aesthetic norm. Moreover, innovations in scar concealment reflect a greater desire on the part of South Koreans to minimize the appearance of scars compared with Americans. As a result, the overall trend in eyelid surgery has shifted from what Dr. Millard described as a desire for “round eyes” to “big eyes,” which encompasses a wider variety of procedures, including epicanthoplasty. In contrast, there is also a concern about having a “big face,” which is why V-line surgery – an invasive surgery that involves a reduction in the width of the jawline – has become so popular in South Korea. And while South Korean aesthetic norms may have been influenced by American surgeons like Dr. Millard, additional influences range from regional colleagues in countries such as Japan and local South Korean culture, similar in process to the unique aesthetic norms that have developed in Brazil. In fact, the V-line surgery is a distinctly Korean creation that reflects a focus on facial proportions such that men and women seek a narrowing jawline that forms a V shape. According to Ms. Hu, an “ideal” face in Korea has big eyes (see above), a pointy nose with a raised nasal bridge, and a V-shaped jawline. This is consistent with the most chosen cosmetic plastic surgery procedures in South Korea. Interestingly, the more “traditional,” unaltered Korean face – more circular, with smaller eyes, round cheeks, and wider noses – is now associated with the standard look of North Koreans.

The differences in aesthetic norms between South Korea and the United States have led to confusion as highlighted by the author S. Heijin Lee in the essay “Beauty Between Empires” in the book Fashion and Beauty in the Time of Asia. A GIF was widely circulated in the United States of what was believed to be a fast scroll of all the candidates for the 2013 Miss South Korea competition. What was striking to people was how similar the faces of the contestants looked. Online commenters considered this a reflection of the sameness of the appearance of South Koreans and heaped scorn on the country for promoting this. The GIF was a photoshopped fake. That people, specifically Americans, would not immediately assume the GIF to be a fake was thought to be indicative of a misunderstanding of Asian diversity and conceptions of beauty.

Like in Brazil, the increasing popularity of plastic surgery reflects the increased wealth and democratization of the country, which accelerated in the 1980s. The body was considered a way to elevate one’s status in society to gain economic and social advantages. Patricia Marx traveled to South Korea in 2015 to learn about why South Korea has become a capital of plastic surgery. She reports that there is a great deal of competition for jobs in South Korea, especially since the Asian financial crisis of the late 1990s. Many men and women in South Korea feel plastic surgery can improve their competitiveness for jobs. This sentiment is reflected in common terms used in South Korean ads for plastic surgery such as “self-management,” “self-development,” and “self-investment.” Competition for jobs is so intense, in fact, that an industry of “face readers” has sprouted in South Korean where one can pay for a non-physician to examine your face and make recommendations for changes with plastic surgery.

Surgeons in the United States Exchanges Ideas and Innovations Among Themselves and International Colleagues

W. David Marx argues in the book Status and Culture: How Our Desire for Social Rank Creates Taste, Identity, Art, Fashion, and Constant Change that humans seek to maximize and stabilize status and that human culture reflects status hierarchies. Even concepts considered separate from culture, such as the idea of beauty, get swept up into it. This theory is consistent with the association of plastic surgery with the wealthy and famous in Brazil as well as the promotion of plastic surgery by the South Korea government through K-Pop groups and Hallyu more broadly. As Mr. Marx argues, media promotion results in taste congruence among individuals across the socioeconomic divide. This process has likely accelerated with the development of social media and online culture. For example, Ms. Hu notes “present-day social media already places a new pressure on everyone to remain forever photogenic, forever young, forever fit and thin, forever wrinkle free.” Further, she writes “the technological gaze keeps feeding us an ever-evolving, ever narrowing beauty ideal.” Increasing wealth and democracy in the context of a free market have allowed Brazilians and South Koreans to acquire the means to purchase plastic surgery, historically a marker of high status. I believe Mr. Marx’s theory is partially descriptive and Ms. Hu are correct, but their arguments are incomplete because they ignore the free agency of empowered individuals to make decisions based on their own, personal desires and values. The internationalization of media and development of a global culture has sped the exchange of ideas between countries and the relative influence of plastic surgeons from across the world, however. To what extent these individual choices are influenced by popular local and global culture remains a question. This is especially acute in a society like South Korea’s that is more communal than the United States and Brazil, a culture in which Elise Hu states:

“A Korean woman who gets plastic surgery to fit in in this way is not looking good just for herself. She is showing respect for others in the community. She is also signifying where she fits – or might fit – in the class hierarchy, such that beauty work or body modification can help a lower-class woman ‘pass’ as a middle- or even upper-class person.”

The development of Brazil and South Korea as major centers for plastic surgery has benefited the world on net. Just as American surgeons have learned from Europeans and vice versa, the more centers for innovation that develop the higher the likelihood safer and more effective techniques and technology will be developed through the increasingly global exchange of ideas. We as plastic surgeons do, however, need to be cognizant of how internet culture pressures some individuals to pursue procedures to their detriment.

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References

  1. DiMoia J. Reconstructing Bodies: Biomedicine, Health, and Nation-Building in South Korea Since 1945. Redwood City, CA, Stanford University Press, 2013.
  2. Edmonds A. Pretty Modern: Beauty, Sex, and Plastic Surgery in Brazil. Durham, NC, Duke University Press, 2010.
  3. Hu E. Flawless: Lessons in Looks and Culture from the K-Beauty Capital. Dutton, 2023.

  4. Jarrin AE. The Rise of the Cosmetic Nation: Plastic Governmentality and Hybrid Medical Practices in Brazil. Medical Anthropology: Cross-Cultural Studies in Health and Illness. 2012; 31(3): 213 – 228.
  5. Lee SH. “Beauty Between Empires: Global Feminisms, Plastic Surgery, and the Trouble with Self-Esteem.” Fashion and Beauty in the Time of Asia, edited by Lee SH, Moon CH, and Nguyen Tu TL, New York University Press, 2019, 69 – 102.
  6. Marx P. “About Face: Why is South Korea the world’s plastic surgery capital?” New Yorker, 16 March 2015.
  7. Marx WD. Status and Culture: How Our Desire for Social Rank Creates Taste, Identity, Art, Fashion, and Constant Change. New York, Viking, 2022.

This blog post is for educational purposes only. It is essential that you have a consultation with your medical provider prior to considering any treatment. This will allow you the opportunity to discuss any potential benefits, risks, and alternatives to the treatment.