You see them everywhere in Lebanon: the women whose faces look as tight as a 20-year-old’s until their wrinkled hands betray them as septuagenarians; the television presenters whose upper lips lump to one side; and all those cute, celestial noses! As you walk down the street you see dozens of faces, male and female, all sporting the same smooth nose with pointed tip. 

It feels like an epidemic of cosmetic procedures all around you. Advertisements for liposuction and filler procedures in places such as beauty or physical therapy centers have become as common as advertisements for the latest hamburger. 

Mind you, reconstructive and plastic surgery can be as vital to a person’s wellbeing and recovery from a burn or accident as any serious surgical procedure. Lebanese specialists do sometimes perform these literally face-saving procedures, and they are to be commended for their work. 

But the bulk of plastic surgery procedures in Lebanon are done for superficial purposes. Though the free-spirited among us would like to think that the Lebanese obsession with cosmetic enhancements is a cliché, the numbers and faces around us force us to face facts. 

Lebanese doctors perform the highest number of plastic surgery operations per capita in the Arab region, and Lebanon ranks among the top 20 worldwide according to the Lebanese Society of Plastic Aesthetic and Reconstructive Surgery (LSPARS). 

Reasons for this obsession vary from an extreme reaction of a society repressed by memories of the civil war to the need to keep up with one’s peers and look as good as they do.

Some believe that physical improvements are not wrong as long as one is comfortable with oneself after seeing the end result in a mirror. While this is arguable, the danger of self-improvements becomes tangible when the practice becomes commercialized to the extent that women are getting Botox injections during their lunch breaks, and not from qualified plastic surgeons. 

Not only the nose

There are currently 83 plastic surgeons in LSPARS — founded in 1967 with just seven members — and they perform an average of 5,000 cosmetic surgery operations annually. This excludes noninvasive procedures such as fillers and botulinum toxin (commonly referred to as Botox), which make up 60 percent of a plastic surgeon’s work. 

Botched operations are increasingly common in Lebanon

Among the 40 percent of procedures that are invasive, the most requested operation remains the rhinoplasty, or nose job, with liposuction and breast augmentation following close behind. “We Arabs have very prominent noses, and while some see this as a symbol of masculinity or national heritage, many opt to have it softened,” explains Antoine Abi Abboud, head of plastic surgery at Mount Lebanon Hospital.  

The domestic market for invasive procedures has grown for nose jobs and breast modifications. Perhaps it is because Lebanon has become an even more image-conscious society. Practitioners tell Executive that the number of men seeking such cosmetic treatments has steadily risen in recent years. “Men mainly seek liposuction if they are overweight and body sculpting which gives them a six-pack appearance,” says Elias Nassif, plastic surgeon at the Bellevue Medical Center. 

Not all cosmetic surgery operations in Lebanon are performed on Lebanese. Arab clients, lured to Lebanon by plastic surgeons’ reputation for excellence and by the relatively low cost of treatments compared to Europe and the United States, account for a significant percentage of total cosmetic surgeries performed in the country.  Also, in an inverted form of medical tourism, many Lebanese plastic surgeons commute regularly between their local clinics and the Gulf, for added exposure and income. 

“When I first started, I could safely say that 50 percent of my clients were from Arab countries,” says Nassif. This percentage dropped close to zero in the summer of 2012 in the wake of Arab travel warnings on Lebanon, Nassif explains. “Now they are on the rise again and international patients constitute 30 percent of my clients,” he adds. Other practitioners cite similar ratios for their Arab clients and tell Executive of seasonal trends where Arab client numbers peak in July/August when many take advantage of the holidays to ‘readjust’. 

Crooked compensation 

The incentive of money not only motivates physicians to specialize in plastic surgery; it also attracts surgeons from different specialties to perform opportunistic procedures. 

“A general surgeon who makes a maximum of a $1,000 on a hernia operation can make $2,000 for a nose job,” explains Abi Abboud.

Legally, any surgeon can perform any surgery, and while dermatologists and ear, nose and throat specialists are technically qualified to perform certain procedures and surgeries, it seems there is ambiguity regarding this issue. “While this is legal, the danger is when a serious mistake occurs due to lack of specialty and then problems will occur,” says Abi Abboud. 

Even among plastic surgeons, there are those who are considered less qualified than others and LSPARS is trying to influence the Order of Physicians to be more selective in licensing plastic surgeons. Sami Saad, secretary of LSPARS and a practicing plastic surgeon, says the problem lies within the system: all a physician needs to do to be allowed to practice in Lebanon is to present evidence of training. 

“Some countries, like Russia, train plastic surgeons only through observation, so when a doctor from such a system obtains a license to operate in Lebanon, he is apt to make errors as he isn’t properly trained,” explains Saad, adding that the Lebanese board of physicians responsible for licensing doctors rarely has plastic surgeons as members, and so it is unaware of the field’s needs. 

Saad gives the example of medical institutions in the US, where students’ internships stretch over several years, more than half of which are spent on hands-on training under the guidance of practicing plastic surgeons. 

Dirty and ugly

Many beauty centers and hair salons in Lebanon have started listing Botox injections, filler procedures and even liposuction on their lists    of services. 

Under Lebanese medical law, it is illegal for anyone except doctors — or those under a doctor’s supervision — to perform injections. Yet these centers continue to provide such services. “These beauticians attend a workshop for several weeks and learn the basics of these procedures, but they lack the years of medical practice. They haven’t studied anatomy and don’t know how the muscles respond to such injections,” explains Saad, adding that liposuction by laser is another treatment provided by such centers, and can result in complications such as permanently burnt skin or hardened fat that becomes impossible to remove. 

“Another danger in those centers is that they use products of unknown sources in their injections, and there are no references or backup if something goes wrong,” explains Saad. “These centers are irresponsible and [in the case of liposuction], which involves anesthesia, they can cause fatal damage,” says Nassif. Plastic surgeons Executive spoke to say they see at least one case of corrective surgery per week from procedures performed in such centers.  

Beauty centers attract clients through their strong marketing campaigns, which physicians are prohibited from mounting by law. In some cases, beauticians go as far as encouraging their customers to buy a Botox injection on the spot, without giving any proper medical advice. “The beautician who was giving me a facial encouraged me to get a Botox injection, saying that it will help me look years younger,” says Hanan, a 42-year-old Lebanese woman in the waiting room of a plastic surgeon. “She said that she could give me one right now, as part of my facial treatment.” 

Hanan did not want to give her last name for fear of embarrassment as her reason for seeing the licensed plastic surgeon was that the beautician had botched the injection and Hanan hoped to have the maltreatment corrected. Other beauty seekers willingly undergo treatments in dodgy centers because of the misconception that the coveted injections cost less there, though LSPARS asserts that their prices are the same and sometimes lower than the centers, in the range of $400 for a filler procedure and $300 for Botox.

Faint hopes

Other than prohibiting physicians from marketing themselves, the Order of Physicians has done little to regulate plastic surgery in Lebanon.  

Consequently, LSPARS has taken upon itself the role of educating the public and raising awareness on the dangers of malpractice in this field. The organization, which has some leverage in its power to grant international recognition of Lebanese plastic surgeons, focuses its awareness work mainly on encouraging the public to only use a licensed public surgeon for any procedure.

Yet, as profits lure and marketing draws customers, it seems naïve to expect that a mere awareness effort will sufficiently alert all Lebanese beauty seekers to the dangers and criminal negligence that might come with some discounted offers of eternal beauty.