James Brice

August 20, 2010

August 20, 2010 (San Francisco, California) — Breast augmentation, liposuction, and other forms of elective plastic surgery are becoming more and more popular in China and India, which rank with the United States and Brazil as top users of aesthetic plastic surgery, according to the first comprehensive global survey of the medical specialty.

The survey was sponsored by the 2000-member International Society of Aesthetic Plastic Surgery (ISAPS) and released to coincide with the ISAPS 20th Biennial Congress.

Results indicate that nonsurgical procedures, such as botulinum-A (Botox) and laser hair removal, were actually performed more frequently in the United States last year than invasive plastic surgery. The trend is leading aesthetic plastic surgeons in the United States to modify their practices to adjust to shifting demand.

The survey found that 17.1 million cosmetic plastic surgery procedures were performed worldwide in 2009, and 3 million of those were in the United States. The top-5 countries were the United States with 3,031,146 procedures; Brazil with 2,475,237; China with 2,193,945; India with 894,700; and Mexico with 835,280.

China and India's prominence can be explained by rapid economic growth, said Foad Nahai, MD, ISAPS immediate past president. In an interview with Medscape Medical News, Dr. Nahai, from Atlanta, Georgia, referred to a recent Wall Street Journal report that revealed that China's $4 trillion gross domestic product has surpassed that of Japan.

"There are rapidly growing middle classes in China and India, and their disposable incomes are growing" Dr. Nahai explained. "Plastic surgery is very popular in China, just as it is in Western Europe and the United States. The media are interested in it. There is always something in the press."

Despite widespread poverty, Brazil has historically been a center for aesthetic augmentation because of a strong cultural association between body image and self-esteem. More liposuction is performed in Brazil than in any country in the world, according to the ISAPS survey.

The number of procedures and the number of physicians practicing plastic surgery in a particular country were strongly correlated. The survey identified 30,817 aesthetic plastic surgeries worldwide. Of that total, 5700 physicians worked in the United States. China was second, with 4250 surgeons; Brazil and India followed with 3824 and 2000, respectively.

On a per capita base, cosmetic procedures were most popular in South Korea. According to the survey, 13.5 procedures per 1000 population were performed in that country of 48.8 million.

Although worldwide use is about evenly split between surgical and nonsurgical augmentation, 57% of the procedures performed in the United States are noninvasive. Survey results indicated that more than 498,000 botulinum and nearly 312,000 laser hair removal procedures were performed there last year. Other high-use procedures include hyaluronic acid (a dermal cream), sclerotherapy, and laser vascular treatments.

The ISAPS survey totals for the United States — limited to aesthetic plastic surgeons — are substantially smaller than figures published by the American Society of Plastic Surgeons (ASPS) in June. By including all providers, the ASPS survey uncovered a 1% decline — to 12.5 million procedures. That survey found that minimally invasive procedures accounted for 88% of total volume. They rose just 1% in 2009, but have nearly doubled since 2000.

Renato Saltz, MD, scientific program director of the 2010 ISAPS meeting, cited consumer preferences for the historic shift to less invasive and relatively less expensive procedures.

"Patients are well-educated about these matters," he told Medscape Medical News. "They know what they want, and they know how these procedures work. There is a big push from industry to spread the word about these procedures.

Dr. Saltz cited the technical exhibit at this year's meeting as evidence.

"You will find only 1 or 2 booths selling surgical instruments," he said. The rest are selling this dream of looking younger and looking better."

To keep pace, aesthetic surgery groups are building upscale health spas and combining them with their surgical practices, according to Dr. Saltz.

"When I finished my medical training in 1989, we never talked about creams, [botulinum], or dermal fillers. Back then, we were just surgeons," he said.

Breast augmentation and liposuction are the 2 most frequently performed surgical procedures in most countries, observed Dr. Nahai. Cosmetic preferences are generally based on a Western standard of beauty, with small modifications to fit the population's ethnic inclinations. Eyelid alterations and nose implants are performed throughout Asia. Surgical upper lip augmentation is popular in Thailand, and Iran has become the world's epicenter for rhinoplasty, he said.

Overall results compiled by Industry Insights, a private research firm in Columbia, Ohio, are accurate within a range of ±4.24% at the 95% level of confidence. The confidence intervals for individual countries vary.

Surveys were initially sent to 20,000 plastic surgeons in an ISAPS database. National professional societies representing plastic surgeons provided data accounting for 31,000 practicing plastic surgeons around the world. When the total number of plastic surgeons in given country was not known, an estimate was supplied by an international organization that maintains a list of surgeons by country.

For nonreporting countries, a regression analysis was performed to estimate the number of plastic surgeons and procedures on the basis of population and economic statistics. This method accounted for less than 2.5% of the global totals, according to the ISAPS.

The study was funded by the ISAPS. Dr. Saltz and Dr. Nahai have disclosed no relevant financial relationships.

International Society of Aesthetic Plastic Surgery (ISAPS) 20th Biennial Congress: Presented August 14, 2010.