It is 9am in a branch of one of Egypt's most famous private eye hospitals in the working class district of Al-Sayeda Aisha. The clinic is teeming with patients from different social classes and backgrounds, but the majority seem to have come from rural areas. Most patients seem to be seeking professional medical advice, but many are also opting for surgical and non-surgical cosmetic procedures, including rectifying upper and lower eye-lids, Botox and filler injections. “It's been years since I had cosmetic surgery on my eye-lids, but whenever I look back I feel glad I made the right decision,” 48-year-old Mona (not her real name) said, expressing her satisfaction. A well-off divorced housewife who likes to wear expensive branded clothes, Mona is waiting for her brother to come out of a similar surgery to remove bags from his lower eye-lids. Mona's looks were probably a source of encouragement for her brother to go for more or less the same surgery. Mona's eye-lids are tightly lifted, giving a youthful look to her green eyes that look rounded under her neatly tattooed eyebrows. Her face is smooth, the absence of any wrinkle of expression on her face is unmistakable, her cheekbones are somewhat plump and she has had her lips permanently coloured. Mona has no difficulty in admitting that she has gone under the knife in order to achieve her current surgically-enhanced beauty. “Everybody is doing it,” she shrugs. Her first introduction to cosmetic surgery was when she was in her late thirties when she wanted to remove the bags from her lower eye-lids and extra tissue on her upper lids. However, since then she has also undergone other minor procedures, including Botox, fillers, laser treatment, permanent make-up, tattooing and laser hair-removal. Her friends have also been through similar experiences, having different procedures ranging from nose jobs to cheek plumps, tummy tucks and teeth whitening. “It really makes a difference psychologically; in fact, it is a beautiful experience,” Mona said in an assertive tone. “After I underwent the surgery, everybody said there was a major change in my looks. I practically lost ten years off my age as a result of going a few hours under the knife. That was a great feeling, and it's worth the money to me,” she said. Mona is not alone. Plastic surgery and minor cosmetic procedures have become common worldwide to the extent that they have grabbed the attention of the world's psychologists and sociologists who have been eager to examine the phenomenon. Cosmetic surgery is defined as the branch of plastic surgery whose purpose is to improve external appearance rather than health. Cosmetic techniques can be surgical or non-surgical, and they include chemical peels, dermabrasion, facial sculpturing, Botox, hair replacement, tummy tucks, permanent makeup, fat injections, nose surgery, injectable fillers, liposuction and silicone implants, among other procedures. Although plastic surgery has been around for decades, in the past it has been largely confined to those having a deformity from birth or due to an accident. It has also been more widespread among cinema and TV stars. Today, however, Mona says that almost all the people she knows in her circle, men and women, single and married, ranging from their mid-twenties to over sixties, have undergone a minor or major cosmetic procedure. The consensus among observers is that the trend has recently also become rife in Egypt's lower and middle classes and among men, who are now said to constitute almost 40 per cent of all those undergoing cosmetic procedures. A study entitled “The Perfect Me: Cosmetic Surgery and the Social Body in Egypt” by María Sánchez Muñoz and conducted in September 2012 at the American University in Cairo (AUC) attests to this growing trend. “Cosmetic surgery has progressively moved away from the medical realm, and today it is advertised as just one more product available for purchase,” Muñoz wrote in her study. “Magazines all over the world feature articles about cosmetic surgery, television shows related to plastic surgery have proliferated in the last decade, and plastic surgeons freely advertise their services on the Internet, television or through the print media.” “Whereas plastic surgery once remained an exclusive technique reserved for the elite for decades,” today, the study maintains, “the current low prices have made cosmetic surgery more affordable to the working and middle-class, gaining more patients every year.” NO LONGER A LUXURY: 28-year-old Zeinab, a single caregiver for the elderly who earns LE 6,000 a month on average, seems to shrug off her daily fights with her mother over cosmetic procedures. Zeinab's mother argues against lavishing money on tattoos and tummy tucks, but Zeinab, who comes from a low-income family living in the working class district of Ain Shams in Cairo, cannot quit her “obsession.” “I understand my mother has other priorities in the light of the current inflation,” Zeinab concedes, pulling her lips to one side of her face, perhaps in regret. But she soon bends over the object of her latest passion, her mobile phone. Like many other people, Zeinab is addicted to posting new pictures everyday on WhatsApp and Facebook, perhaps in search of more likes for her improved looks. A recent Reuters article also attempted to gauge this growing trend among working-class Egyptians, suspecting that “working-class Egyptians are getting Botox, breast implants and tummy tucks in the hope that the cosmetic surgery once reserved for a wealthy elite will boost their own marriage and job prospects.” “Illiterate housewives fearing abandonment, soldiers mocked for flabby chests and overweight women struggling to find a husband sometimes pay with their own blood, rely on charity, borrow money from family and friends or turn to unlicenced cut-price private clinics for procedures,” the Reuters article wrote. Mohab Gamei, an oculoplastic surgeon in Cairo, attests to the growing trend in Egypt in general, including among the working classes and men, for cosmetic procedures. “We have patients belonging to all social classes. Those from the working class are usually covered by medical insurance that help them pay for such surgery,” Gamei told Al-Ahram Weekly. “In many cases, patients are seeking cosmetic surgery for medical reasons – there are cases when upper lids are sagging to the extent that they constitute a psychological problem for the patient. It is for this reason that we do not consider ourselves to be simply cosmetic surgeons because many surgical procedures have good medical reasons.” Although the prices of cosmetic procedures, as well as of Botox and fillers, have more than doubled over the past few months following the floatation of the Egyptian pound last November, Gamei insists that this inflation has not negatively impacted the trend for cosmetic procedures. “People have not stopped opting for cosmetic procedures despite the fact that the prices of fillers and Botox have more than doubled. Patients understand that this is not their doctors' fault,” he said. Hossam Foda, a professor of facial plastic surgery at the Alexandria Medical School, agrees that cosmetic surgery is no longer reserved to the wealthy classes or to female clients. “The revolution in cosmetic techniques and their improved results, reported on 24-hour news, have encouraged people belonging to the middle and lower social strata to jump onto the beautification wagon band,” Foda told the Weekly. In the meantime, Foda explained that government-affiliated hospitals also now offer low prices, making plastic surgery more affordable to limited-income patients. However, these operations, he warned, “are usually not fool-proof, and many patients may seek to repeat the surgery to rectify deformities.” Foda is described by experts at the University of Amsterdam in Holland as one “of the world's most experienced rhinoplasty surgeons,” and he provides training for surgeons from all around the globe. Only those belonging to the wealthier classes in Egypt and non-Egyptian patients seek Foda's expensive expertise, it being particularly prized by people from the middle classes opting for perfectly done nose jobs as there have been cases of fraudulent centres and inefficient doctors sprouting up and performing poorly done operations that in some cases can cause problems. The Ministry of Health has been warning against such uncertified centres, and since many people remain unable to afford to do their surgery with Foda they may opt for the 50 per cent discount he offers patients agreeing to be the subjects of his global training programmes. “Most of my patients are either non-Egyptian or wealthy Egyptians who do not even ask about prices,” Foda said. “But I can safely say that the recent inflation has affected the middle social strata who now line up on a three-to-four-year waiting list of patients willing to take the 50 per cent discount and allow trained surgeons to attend the surgery and take photographs as part of their training.” EXPLAINING THE TREND: The reason why people go to so much trouble to get a nose job or a tummy tuck in a country afflicted with so many economic, political and social woes is an interesting point of study. First, it is a global issue. The International Society of Aesthetic Plastic Surgery (ISAPS) has recently estimated that more than 23 million cosmetic surgical and non-surgical procedures were performed worldwide in 2013, a number that has probably more than doubled with the spread of a wide range of new cosmetic techniques. Women constitute 87.2 per cent of those undergoing such procedures, with breast augmentation and liposuction the most-performed procedures, according to the ISAPS. Although there is no accurate figure for the number of cosmetic procedures in Egypt, the ISAPS estimates that the country ranks 19th among those with the highest number of plastic surgeons. “In the case of Egypt, there is no official data for the number of patients undergoing cosmetic procedures each year,” Muñoz wrote in the AUC study. “However, all the surgeons interviewed for this study confirmed the growth trend of the plastic surgery market in Egypt. Women from different social classes undergo both surgical and non-surgical procedures,” she wrote. All the surgeons participating in Muñoz's research agreed that rhinoplasty was the most requested procedure among young Egyptian women aged between 19 and 25 years old. “Amongst older women, abdominoplasty, liposuction and fillers seem to be the most popular procedures. What almost all surgeons and patients noted was the growing popularity of Botox among women in their twenties,” she wrote. She suggests that the “current rampant social inequalities, the huge gaps between different economic levels, the ‘westernisation' of the social elite, the controversial position of women in society, the escalating role of the media and the Internet, and the height of the Islamist influence” may all be elements affecting the popularity of cosmetic procedures in Egypt. Sociologist Hoda Zakariya argues against claims that the phenomenon has any links with late marriages. “This should not be a point of discussion, if you do not want your research to lose its value,” she said. “As you can see, most of the women who go for such cosmetic procedures have two or three children before they do so,” she added. Instead, Zakariya says the craze is the product of media propaganda that tends to focus on the beauty of the body rather than the intellect, wit or soul. It focuses on presenting dancers and movie stars, rather than intellectuals and scientists, as the models that society should follow. “Women may lose self-esteem if they do not fit into the mould introduced by the media,” she said. “And just like any woman wanting to feel feminine, those belonging to the working class have been the first prey of the media propaganda, perhaps with many less-educated women feeling that it will make them look like women from the higher classes.” The fact that society puts a greater emphasis on looks rather than wits has also been a strong drive for doctors who “would rather focus on advancing beauty techniques in their labs than finding a solution for such endemic diseases as bilharzia, for instance, because they know the beauty business will always sell,” according to Zakariya. “Doctors and fashion designers are the ones who have created this beauty craze because it is a product that sells,” she added. “The media in turn makes a fortune advertising such techniques, and society as a whole, including all classes and both genders, falls prey to this immense money-making machine.” Doctors, however, insist that they refuse to carry out unneeded surgery. Gamei says that he declines to do procedures “for those with unreal expectations, because they are hard to satisfy,” while Foda refuses to give television interviews because he does not want to be part of “fraudulent media propaganda.” Many plastic surgeons would agree with Gamei that “the spread of social media has been a strong drive behind many patients' cravings for better looks.” And a study released recently by the American Academy of Facial Plastic and Reconstructive Surgery similarly showed that “one in three surveyed doctors have seen an increase in requests for surgery due to patients' dissatisfaction with their image on social media.” As a result, American surgeons saw a 10 per cent increase in rhinoplasty from 2012 to 2013, a seven per cent rise in hair transplants, and a six per cent in eyelid surgery, according to the report. Research has also shown that people become significantly more dissatisfied with their appearance after being shown TV ads featuring exceptionally slim and beautiful people. With many now competing to look like Lebanese film stars and singers, more and more people may opt for the wide range of handy, largely affordable procedures that are now available that promise something for all types of skin and promise to repair damaged hair and improve body shape and facial features, sometimes even bestowing the looks of Hollywood stars and removing ten years of age in a ten-minute session. The spread of the selfie has also made people more obsessive about their facial features than ever before, as one cosmetic surgeon speaking to an MBC TV morning talk show explained. The surgeon said that many patients are now asking for the removal of a sagging double chin or a long nose that does not exist in reality, thanks to the selfie's characteristically distorted camera angle that does not provide an accurate representation of the face. “There is no doubt that many cosmetic procedures are mainly psychological in origin, and in many cases we refuse to do unrealistic cosmetic procedures as a result,” Gamei said. Independent American researcher Brett Lunceford has been among those attempting to examine “the ethics of seeking bodily perfection,” publishing a book on the topic entitled “Global Issues and Ethical Considerations in Human Enhancement Technologies”. In his book, Lunceford suggests that cosmetic procedures are on the rise because the global culture puts women in particular in the “unenviable position” of choosing between surgically enhancing their bodies and “mattering at all in society”. “Judging women on their looks acts as a strong incentive to fit into the mould of generally accepted beauty,” Lunceford said. “The driving force behind cosmetic surgery, to an extent, is sexuality.” Muñoz, however, argues against some feminist claims that “women who undergo cosmetic procedures are largely pressured by a patriarchal, sexist society.” She supports more moderate viewpoints suggesting that “cosmetic surgery can be empowering, as patients freely choose to undergo these procedures in order to improve their lives and social positions.” “I suggest that women who undergo surgery for cosmetic reasons are willing to sacrifice and invest their money and time within the constraints of a patriarchal culture to feel better with themselves and the society around them and to achieve ‘a moment of triumph' as a result,” she said. “They do not describe their decision as being the result of oppression or the tyranny of the beauty market.” 24-year-old Menna, who has had rhinoplasty, is quoted in Muñoz's study as saying that the surgery was “worth the pain because it positively affected my self-confidence. I have not regretted my surgery for a second, and if you ask me if I would do it again… the answer is yes, for sure,” she asserted. Foda has now beautified 6,000 noses in Egypt, and he insists that almost all his women patients had taken the decision to undergo the surgery on their own without any pressure even from their husbands. “They just do it for their own sakes, not for the sake of their husbands as many seem to believe. They do it to feel more confident and empowered and to stop shying away from cameras and the rest of society,” Foda told the Weekly. Foda explains the trend in favour of more cosmetic surgery in the light of the achievement of better self-satisfaction and higher self-esteem. It is a kind of personal empowerment, which, he insists, applies to both sexes. “More and more men are seeking cosmetic procedures because they feel that improving their appearance helps them fit into society better, especially those working in business and politics,” Foda said. IMAGE AND SOCIAL ACCEPTANCE: Recent studies of the importance of body image in society have concluded that “attractive people have distinct advantages,” for example. “Concern about appearance is quite normal and understandable,” wrote a recent UK study entitled “Why we look in the mirror”. The study, issued by the UK-based non-profit organisation Social Issues Research Centre (SIRC), argues that attractive children are more popular with classmates and teachers, attractive applicants have a better chance of getting a job and receiving higher salaries, and attractive people may even be found guilty less often in court. “The ‘bias for beauty' operates in almost all social situations, and all the experiments show we react more favourably to physically attractive people,” the SIRC study concluded. The study also shows that this is not confined to women only, as “in most recent research there is some evidence of an increase in body-dissatisfaction among males.” “As well as some early-adolescent boys, men undergoing the so-called ‘male menopause' or mid-life crisis – i.e. men between the ages of about 45 and 55 – are most likely to be dissatisfied with their appearance,” according to the SIRC. This could help explain the increasing numbers of men resorting to cosmetic procedures in Egypt.
