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  • Plastic surgeons strive to help their patients look their best possible. But what is the “best possible”? The standards of beauty have recently been called into question, with the sudden rise of Asian plastic surgeries across the globe. According to the American Society of Plastic Surgeons (ASPS), plastic surgery among Asian-Americans increased 58% from 2004 to 2005, translating into 437,000 surgeries. The growing number of Asian-Americans going under the knife has generated concern among Asians about whether plastic surgery is erasing Asian ethnic features and creating a “Westernized” look in its place. In America, the concern is focused on Asian-Americans undergoing surgeries with results that follow a more typically Caucasian standard of beauty, and thereby possibly losing their unique ethnic identities as Asians.

    In Asia, there has also been tremendous growth in the plastic surgery industry, with Japan, Thailand and China acting as hotspots for licensed and illegally-performed procedures. Up until 2001, China had a ban on plastic surgery, hoping to preserve traditional, non-Western looks and styles. According to a Zee News article, plastic surgery is currently a 2.4 billion (USD) industry in China, with about one million procedures done a year. In Japan, the industry is even larger, with $18.7 billion dollars spent a year. There is less controversy in Asia about “Westernization” through surgery – procedures are done to improve the general appearance of the patient, but not in light of a certain ideal. Patients mostly cite life and career advantages as their reasons for surgery.

    In America, patients and surgeons generally also cite a wish for an improved overall appearance, and not for the look of a specific ethnicity. Plastic surgeons are developing specialized procedures that help create natural-looking adjustments among Asian-Americans, to improve the appearance of their patients while simultaneously preserving their ethnic look. The most popular procedures requested by Asian patients include a double eyelid surgery where a crease is created in patients born with a single eyelid, liposuction, breast augmentation, and rhinoplasty (nose reshaping).

    Rise in Asian Plastic Surgery

    In America, the number of Asians opting for cosmetic surgery has skyrocketed, with ASPS reporting a 33% increase among Asian Americans from 2005 to 2006, from 437,000 Asian patients having surgery in 2005 to over 610,000 in 2006. Furthermore, the American Academy of Facial Plastic and Reconstructive Surgery shows a 35% rise among Asians in non-invasive procedures such as BOTOX between 2005 to 2006.

    The increased popularity of plastic surgery in America is due to a number of changes. According to an article in New America Media, a collection of ethnic news organizations, plastic surgeons traditionally held a European/Caucasian standard of appearance, characterized by Roman noses and double-eyelids. It was not until a few decades ago that medical schools recognized ethnic differences in appearance. The rise in practices and plastic surgeons that cater specifically to the needs of Asian patients has instilled confidence in Asian patients to undergo procedures without fear of losing their ethnicity. Techniques have been developed and refined that are tailored specifically to creating a more natural appearance in Asian patients undergoing cosmetic surgery. The combined effects of the plastic surgery industry recognizing and promoting different procedures for different ethnicities could have encouraged a greater number of Asian patients to opt for plastic surgery.

    Outside the United States, plastic surgery is booming in Asia. Hong Kong is ranked 6th in the world for plastic surgery procedures done per capita in 2002, with almost 74 per 100,000 people, according to nationmaster.com, a graphical database. Taiwan ranks 13th, Japan 18th, and Singapore and South Korea come in at numbers 26 and 27, respectively. Furthermore, Japan is ranked fourth in the number of plastic surgery procedures done per country, with almost 43,000 performed in 2002. Taiwan is ranked 14th, and South Korea is ranked 15th, with about 10,000 procedures each, and Hong Kong 18th, with 5,000. According to Time Asia, there were one million procedures done in Taiwan in 2001, twice the number performed in 1996. Surgeons estimate that one in ten adults in Korea has done some type of cosmetic procedure and even children get their eyelids done to create a fold for a double eyelid-effect.

    In Asia, a large number of cosmetic procedures are performed illegally by unlicensed doctors. For example, Time Asia reports that there are only 43 licensed plastic surgeons in Indonesia — a country with a population of 230 million – yet an estimated 400 illegal surgeries are performed a week in Jakarta, Indonesia’s capital, alone. Illegal procedures are also rampant in China, as reflected in the more than 200,000 lawsuits filed against practitioners between 1992-2002, according to the China Quality Daily. The main reason for illegal plastic surgery is money, as the business is extremely lucrative. For example, clinics in Japan alone can make $100 million a year on non-invasive procedures.

    Top Asian Plastic Surgery Procedures

    According to the ASPS, the three most commonly requested surgical procedures among Asian-Americans in 2006 were nose reshaping, breast augmentation and eyelid surgery. The top five requested surgical procedures overall in 2006 were breast augmentation, nose reshaping, liposuction, eyelid surgery and tummy tucks. An examination of different procedures follows below.

    Double-Eyelid Surgery (Blepharoplasty)

    Asians are increasingly asking their plastic surgeons for wider and rounder eyes. Other Asian patients who have mono-lids (no crease in the eyelid) are seeking to have a fold created to achieve a double-eyelid. For these reasons, eyelid surgery (blepharoplasty) is the most popular plastic surgery done among Asians in the world. In the United States, eyelid surgery ranks as the third most poplar plastic surgery done by Asian Americans, behind nose reshaping and breast augmentation. For Caucasians, the reason for doing eyelid surgery is to reduce the signs of aging, lift droopy eyelids, and remove under-eye bags. This is done by removing excess fat, skin and muscle around the eyes. Among Asians, however, the more frequently requested procedure is a double-eyelid surgery, which creates a second fold in the upper eyelid. According to an article by plastic surgeon Dr. Charles Lee, approximately 50% of Pacific Asians (Chinese, Japanese and Korean) are born with a natural double-eyelid and thus do not need a double-eyelid surgery. For those who are born without a fold, getting a double-eyelid surgery can create a natural-looking crease.

    For those Asians with a double eyelid, the crease curves: it starts out small and near the eyelashes at the corner of the eye, and then gradually becomes larger, reaching its maximum at the center of the eye. The crease then continues in a parallel slope downward away from the nose. Among Caucasians, the crease does not run parallel to the eyelash line, but instead folds in an upside-down “U” shape. The crease in Caucasians is also about 20% larger than an Asian eyelid crease, according to Dr. Charles Lee. For the 50% of Asians who do not have a crease, a natural-looking fold can be created without “Westernizing” the patient.

    There are various techniques that can be used to achieve the double-eyelid. The first one, often called the “suture method” involves making small incisions inside the lid along the new crease line and placing tight sutures underneath the skin. The skin is lifted and folded back to create the fold. The suture method has the advantage of being less invasive than other double-eyelid methods as little surgery is involved, the procedure costs less, and can be performed quickly, often in as little as fifteen minutes. Despite these advantages, the suture method has some serious drawbacks in that the result is not long-lasting and the crease fades away after several years because the sutures weaken after a few years. In some cases, the sutures can break after a few months and lead to the disappearance of the crease. This method also results in a less natural look, as the newly-created crease is always there and does not go away when the eyes are closed or when one blinks. Furthermore, the crease created by the suture method does not follow the shape of the patient’s eye as closely as the full incision method (discussed below), and the resulting double-eyelid looks more “Western” than Asian. While the suture method is often described as being non-surgical, it does actually involve making a few incisions and the scar that results is virtually the same as the scar that is formed from the superior full incisional method. Finally, the suture method has another key limitation in that future eyelid surgeries that are necessary to do once the crease fades are more difficult and expensive to perform because of the formation of scar tissue resulting from the incisions. For these above reasons, the suture method is less favored by many plastic surgeons compared to more effective and long-lasting incisional methods.

    Today, the “gold standard” in double-eyelid surgery is the full incision method, where a crescent-shaped incision is made along the new crease line, and in the process small strips of muscle and orbital septum are removed and in some cases also some fat. The amount of tissue removed affects the height and shape of the newly created crease. Then, the two sides are sutured together permanently. The incision method is a superior technique because of the long-lasting results that it produces and there is no risk of sutures breaking since they do not play a role in creating the crease. The incision method is more natural-looking and does not have the problem of creating a permanent crease, as when a person closes or blinks their eyes the crease disappears.

    There is also a hybrid method called the Double Stranded Twist (DST) method that combines the suture and incisional techniques, where a series of small incisions are made to remove fat, while the lid is still lifted through the use of sutures. This technique leads to longer-lasting results than the less invasive suture method and patients reportedly do not experience weakening of the sutures and loss of their crease. According to an article in the American Society for Aesthetic Plastic Surgery (ASAPS) peer-reviewed journal, the results from the DST method have lasted as long as 10 years. Furthermore, the procedure is said to be “virtually scar free.”

    Following an eyelid surgery, patients may experience swelling. Bruising can also occur and last anywhere from one to two weeks to a month. There may also be uncomfortable side effects on the eyes, such as gumminess, burning, itching, or sensitivity to light. Patients are mobile after a few days, and after two weeks, these side effects begin to subside. Scars may show slightly for at least six months, at which point they fade away. There are various products one can use to accelerate the healing process and minimize bruising and swelling, including cold/hot eye compresses, homeopathic remedies such as Arnica Montana and Bromelain, vitamins, scar reduction products, and wedge pillows. Learn more about eyelid surgery recovery products that can accelerate healing, reduce swelling and bruising, and minimize scar appearance.

    The double eyelid, achieved through the surgery, does create a rounder, bigger appearance of the eye and looks more “Western” than a monolid. However, plastic surgeons who perform this surgery are careful to state that they do not want to change a patient’s ethnic appearance, but instead want to make their patients look the best possible while retaining their patient’s ethnic characteristics. The results of the eyelid surgery can be regulated by the doctor, who can create a double eyelid without overly “westernizing” the look of the patient. While women seek a more dramatic result with a higher crease, men opt for a more conservative lower crease which does not look overdone. Beyond the aesthetic benefits of the procedure, women patients who have had double eyelid surgery frequently cite greater ease of applying eyeliner as a major benefit of doing the surgery.

    Nose Reshaping (Rhinoplasty)

    As with blepharoplasty, nose surgery (rhinoplasty) differs between Caucasians and Asians. Among Caucasians, rhinoplasty is typically performed to reduce the nose and help it fit better with the face, while the nose is usually augmented among Asians. According to Dr. James Penoff, Asians usually have “flat or low nose bridges,” and “poorly projected nose tips.” Consequently, Asians seek to address these issues in their nose reshaping procedures.

    During the surgery, the skin is separated from the underlying bone and cartilage, and an implant is placed to shape and augment the nose. The implants are typically alloplastic (artificial material) rather than live tissue, because of the relative scarcity of the body’s tissue in comparison to the augmentation required, according to an article by Dr. Lee. Scarring is minimal, when the opening is properly closed. There may be soreness and swelling in the face post-surgery and some bleeding is also common. Patients are usually mobile after two days, and a full recovery time is about one to two weeks. Learn more about nose surgery recovery products that can accelerate healing, reduce swelling and bruising, and minimize scar appearance.

    Plastic surgeons working with Asians emphasize the desire to make their patients look the best possible, as with blepharoplasty, and deny working towards a Western standard of beauty. Instead, a more defined nose can add balance to a face.

    Chin Surgery (Mentoplasty)

    Chin surgery is often done in conjunction with nose surgeries to enhance the effect, because nose reshaping can disrupt the balance of a face. The surgery is done by making an incision along the jawline on the bottom of the chin, or in the inside of the lower lip between the lip and gum. In chin augmentations, synthetic material that can be shaped as desired is implanted. In chin reductions, surgeons sculpt and reposition the bones into the desired shape. The incision is then closed, with minimal scarring. Soreness, swelling and bruising is common after surgery, with these symptoms slowly diminishing and fading away over a period of about six weeks. Patients may need a soft-food diet for the first few days after surgery, to limit chewing and strain on the chin.

    Breast Augmentations

    Surgeons are careful to emphasize that breast augmentations are carefully structured to fit each patient’s individual body frame, so that the increased bust size does not look unnatural. Since Asians generally have smaller, narrower bodies, a modest increase in bust size is encouraged as opposed to large implants. Incisions can be made in different areas — along the fold under the breast, the areola, or the armpit — depending on the patient’s body and preference. Saline or silicone implants can be placed behind breast tissue or between the pectoral muscle and chest wall. Scarring is minimal. Mild soreness and a burning sensation may occur post-surgery, but the patient is usually able to resume some activity within the first week. Swelling that occurs takes anywhere from three to five weeks to subside. Learn more about breast augmentation recovery products that can accelerate healing, reduce swelling and bruising, and minimize scar appearance.

    Liposuction & Tummy Tuck (Abdominoplasty)

    Both liposuction and tummy tucks are procedures performed to help improve the contour of one’s body and reduce fat deposits. Among Asians, fat is more likely to collect on the arms and waist, resulting in liposuction procedures commonly done in those areas. While liposuction is effective on the legs of Caucasians, it is less effective on Asians because muscle — as opposed to fat — accounts for most of an Asian’s leg mass.

    Tummy tucks specifically focus on removing excess fat and skin in the middle to lower abdomen. Tummy tucks result in a permanent scar for every patient. However, there is a mildly increased concern for Asians when it comes to scarring, as less than 3% of Asians develop keloids. Keloids occur when the scar tissue grows past the edges of the original wound, resulting in a larger growth than normal. Fortunately, keloids can be treated with scar reduction creams such as Kelo-cote and Scar Esthetique, as well as with silicone scar sheets manual massaging. Learn more about liposuction recovery products that can accelerate healing, reduce swelling and bruising, and minimize scar appearance.

    Face Lifts (Rhytidectomy)

    Due to having thicker, tighter skin, and moderately pigmented skin that ages well, Asians usually choose to have face lifts later in life than Caucasians. Asians who do opt for face lifts generally desire a younger appearance, through tightening skin to reduce sagging and wrinkles. Face lifts are also done differently among Asians and Caucasians due to differences in facial anatomy. Caucasians who get a face lifts generally need to reduce sagging along the jawline, neck, and lips. In contrast, Asians experience less sagging in the lower face, due to higher cheekbones, and more sagging in the upper area because of a flatter forehead. For this reason, a brow lift (forehead lift) may be more appropriate for an Asian plastic surgery patient needing to correct signs of aging in the foreahead area. In brow lifts, incisions are made along the scalp, and the sagging skin in the forehead is raised to tighten it. In face lifts, muscles are also tightened, fat may be removed, and the skin then re-draped over the incision. Mid facelifts can also be performed when the cheeks begin to sag due to age, with incisions made below the lower eyelid, or behind the ears. Discomfort can occur, such as swelling or numbness, but disappears in weeks. Bruising may also be apparent for up to two weeks. Learn more about face lift recovery products that can accelerate healing, reduce swelling and bruising, and minimize scar appearance.

    Cheek Surgery (Malarplasty)

    Caucasians generally opt for cheek surgery to better define their cheekbones. For Asians, however, the opposite holds true as most Asian patients want to reduce highly defined cheekbones to improve the balance of their face. This can be done by making an incision behind the lip or along the hairline, and then shaving the bone or pushing it inward. According to a Time Asia article, Botox injections are also used to atrophy muscles and shrink cheeks. Numbness and bruising can occur and may last for anywhere from a few days to a week or longer. Swelling may also occur and may take anywhere from weeks, a month or longer to fully resolve itself.

    BOTOX Injections

    As the leading non-surgical treatment among Caucasians, Botox is used by Caucasians to eliminate wrinkles, and to create a more youthful appearance. The toxin botulinum paralyzes muscles temporarily, resulting in smoother skin. Botox is also the most popular minimally-invasive treatment among Asians, according to ASPS. While Asians use Botox to achieve a younger facial appearance, Botox is also used for other purposes, especially in Asia. Botox can be injected along the jawline to reduce the jaw’s width, or into the calves to achieve a slimmer look. Botox is also used to reduce the size of cheeks (see above).  Learn more about Botox injections recovery products that can accelerate healing, and reduce swelling and bruising.

    So Are Asians Trying To Look More White?

    These days, there is a quiet dispute happening among Asians about whether Asians going under the knife are subconsciously trying to look more white. Asians who have been cosmetically enhanced claim that their reasons for surgery are to look better, but that they want to remain natural and do not want to erase their ethnic characteristics. Plastic surgeons are also careful to emphasize that when they perform these procedures on Asian patients, they have the patient’s best interests in mind, stating that they are attempting to create a better personal look for each patient, and are not working towards a Caucasian ideal or “standard” of beauty. This is validated by the rise in Asian plastic surgery techniques whose objectives are to preserve the person’s ethnic look and whose results are more subtle. For example, doctors are increasingly more conservative in removing eye fat in the lower eyelid, which leads to a more subtle change that does not make one’s eye look Caucasian.

    This growing movement towards striking a balance between the desire for cosmetic enhancement and the need to keep one’s Asian ethnic traits is dubbed as “Ethnic correctness” by Anna M. Park of Audrey Magazines. “With a growing appreciation for diversity and a higher social awareness come advances in technique and deeper understanding of the anatomy of the Asian eye, resulting in more ethnically sensitive procedures.”

    While ethnic correctness sounds great in principle, it’s still difficult to deny that rounder eyes, double-eyelids, a more prominent nose and chin, or bigger breasts are not in any way steps towards a Caucasian beauty standard. After all, bigger eyes and breasts are the stuff of Caucasian beauty standards. As a result, there is a contradiction between what the patients and surgeons are saying, and what the actual cosmetic results show.

    Perhaps it is not so much that Asians are subconsciously “westernizing” their ethnic looks, but rather that the Western beauty ideal is becoming a universal beauty standard embraced by people of all ethnicities and nationalities. As globalization continues to take the world by storm, cultural barriers are breaking down. As these barriers disappear, the Western beauty standards could become more and more widespread, especially through the increased accessibility of international media. Yet while certain attributes of the Western ideal become universal, certain ethnic characteristics will be retained, such as a generally Asian look…but with modified eyelids, bigger breasts and a more projected nose. This is confirmed by Time Asia, which says that the Asian trends towards bigger breasts, bigger eyes, and double-eyelids are parts of the “leggy, skinny, busty Western ideal that has become increasingly universal.”

    It is important to note that there is a divide between American Asians and Asians living in Asia in their feelings about and reasons for cosmetic surgery. In America, the procedures are simply that – cosmetic — and done for a improved appearance. In Asia, however, many patients cite careers and job opportunities as the reason. According to a Time Asia article, it was difficult for some women to get jobs and support themselves because employers discriminated based on appearance. Men in Asia, especially those in the media industry, cite a need to look “trustworthy” and appealing to audiences.

    It also seems that American Asians are more likely to worry about whether plastic surgery will affect their ethnic identities. One theory is that in Asia where people have similar eye features, an eyelid surgery will give them a unique look, while in America having such a procedure may make their look more common. For these reasons, American Asians may be more cautious about plunging into plastic surgery and desire techniques that keep their ethnic look.

    Asian Celebrity Plastic Surgery

    In America, many celebrities retain their decidedly ethnic looks, such as actresses Zhang Ziyi, Sandra Oh and Lucy Liu, none of whom have sparked controversy for their looks. Their retention of their ethnic look does not seem to have affected their careers, either.

    Others of a different generation, however, have opted for surgery, such as action film star Jackie Chan, who underwent a blepharoplasty (double-eyelid surgery) in 1976. It is said that he wanted a more “Western” appearance. Shortly after, in 1980, he began starring in foreign films — namely American ones.

    There is much more speculation about celebrities and plastic surgery in Asia than America. They seem to have more work done in all areas of their body, from lifts to liposuction because of an increased pressure to constantly look pleasing. Many celebrities come under fire for rumors of having plastic surgery done, through compared “before” and “after” pictures. There is speculation that international film star Gong Li has had work done. Japanese pop singer Ayumi Hamasaki is rumored to have had 30 to 40 surgeries total, and there has been rampant speculation about Hong Kong actor Raymond Lam having repeated nose jobs. There was also speculation about Tracy Ip, Miss Hong Kong 2005, and Chinese television hostess Li Xiang, both of whom have denied rumors of surgery. Recently, Korean singer Kim Dong Wan of the boy band ShinHwa admitted that he had a nose job after having previously lied that he fell of the stage during a performance and broke his nose. Also, Singaporean blogger Dawn Yang, who was voted “Hottest Blogger” by hottestblogger.com, and featured in several magazines for her looks, sparked controversy in late 2005 when photos of her in junior college were leaked, in which she looked markedly different. She still has not made a definitive statement about the issue to this day. It doesn’t seem to have hurt her career, however, as she is currently filming an Asian television drama.

    Hong Kong model and actress Gaile Lok is one of the few celebrities who revealed that she had breast augmentations, and later removed them due to health problems. Lok actually came under greater media fire for dating Hong Kong actor and singer Leon Lai in 2006 than for her breast enhancements.

    The one major, well-known celebrity who has not had any surgery is one of Asia’s most popular current singers and actor Rain, who looks traditionally Korean yet is still rapidly gaining an international fanbase. Rain admitted in a CNN interview that he was actually rejected from several initial auditions for being “too ugly,” and for not having double-eyelids.  It is said that he has not had any plastic surgery, which does not seem to have hindered his fame — he was named one of Time magazine’s “100 Most Influential People Who Shape Our World.”

    Plastic surgery, a complex topic, is only further complicated by ethnic considerations. There is no one standard of beauty for everyone, and surgeons try instead for the “best possible” personal result. Differing techniques for procedures do need to be developed, to address the varying needs of different ethnicities. If nothing else, one thing is clear: cosmetic surgery is personal, and every issue needs to be addressed personally.

    This is the debut article of a new area on Make Me Heal which will feature daily articles on Asian Plastic Surgery News and Ethnic plastic surgery.

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