Cracks in the mir­ror

more aus­tralians are hav­ing cos­metic surgery on body parts usu­ally hid­den from pub­lic view. and some­times the re­sult is fa­tal.

The Courier-Mail - QWeekend - - UPFRONT - STORY SU­SAN JOHN­SON PHOTOGR APHY DAVID K ELLY

How med­i­cal tourism for van­ity’s sake can be fa­tal

In to­day’s world of self­ies, but­tock en­hance­ment and Kim Kar­dashian fa­mous-for-be­ing-fa­mous celebrity, it’s hard to be­lieve that plas­tic surgery be­gan in the grim years of World War I as a way of giv­ing hope to sol­diers who’d had parts of their faces blown off. How did we get here from there? How did we ar­rive at a point where young women ask sur­geons to make their lips look like An­gelina Jolie’s? And why are men and women want­ing to bleach “dis­coloured” gen­i­tal and anal ar­eas, and young women ask­ing doc­tors to give them a “Barbie doll slit” in place of the vag­ina they were born with?

Ac­cord­ing to new re­search at Flin­ders Univer­sity in South Aus­tralia, al­most one in five Aus­tralian women is in­ter­ested in hav­ing “de­signer vag­ina” surgery . Li­po­suc­tion pro­ce­dures now ex­tend to re­duc­ing the mons pu­bis in women want­ing to “en­hance” their fash­ion sil­hou­ette. And rib-crack­ing corsets are mak­ing a come­back (re-styled as “waist train­ers”), just as “thigh gaps” are be­com­ing so last year. It’s not just ul­tra-white teeth and spray tans, you should also con­sider your “side bum” – think rap­per Nicki Mi­naj and her tiny waist and plump be­hind. There’s no longer any part of the hu­man body that can’t be im­proved. But there are risks.

In March, 29-year-old former Gold Coast woman Evita Sar­monikas, known to her friends as Eva, died on the op­er­at­ing ta­ble thou­sands of kilo­me­tres from home. She had trav­elled from Syd­ney to the Mex­i­can town of Mex­i­cali, near the US bor­der, to have sil­i­cone im­plants in her but­tocks. The doc­tor who op­er­ated on her was the same man threat­ened with le­gal ac­tion in 2012 by the owner of the world’s most fa­mous butt, Kim Kar­dashian, for us­ing her im­age in his ad­ver­tis­ing with­out per­mis­sion. Mex­i­cali is a hub for “med­i­cal tourism” and Dr Vic­tor Ramirez, the sur­geon who per­formed the surgery, has since been stood down by the Mex­i­cali Col­lege of Plas­tic Sur­geons un­til an in­ves­ti­ga­tion into Eva’s death is com­plete. Ac­cord­ing to lo­cal me­dia, the mat­ter is be­ing in­ves­ti­gated by the Mex­i­can at­tor­ney-gen­eral’s de­part­ment.

Although the hos­pi­tal (since closed) where Eva died per­formed an au­topsy and wished to cre­mate the body af­ter­wards, her fam­ily de­manded a sec­ond, in­de­pen­dent au­topsy. The first sourced the cause as a pul­monary em­bolism lead­ing to a heart at­tack, but the sec­ond au­topsy found that Eva’s right lung had been per­fo­rated by an in­stru­ment, caus­ing a haem­or­rhage that led to her death. Eva’s sis­ter, An­drea Sar­monikas, told Qweekend dur­ing a brief visit to Aus­tralia that the sec­ond au­topsy is be­ing re­viewed and that the case has at­tracted na­tional pub­lic­ity in Mex­ico. She has been liv­ing there since her sis­ter’s death and is “push­ing for a trial date”.

“Be­cause the other vic­tims [of botched cos­metic surg­eries] were Mex­i­cans, noth­ing was be­ing done, but be­cause Eva was Aus­tralian and we’ve been do­ing a lot of me­dia, we’ve been putting pres­sure on them,” An­drea says. In a Face­book trib­ute page cre­ated for her sis­ter, she wrote that she would re­main in Mex­ico un­til the in­di­vid­u­als “who caused my sis­ter’s death take full re­spon­si­bil­ity”. In an in­ter­view with the ABC’s 7.30, An­drea said Eva be­lieved she had in­ves­ti­gated Dr Ramirez’s cre­den­tials and checked out var­i­ous rec­om­men­da­tions be­fore pro­ceed­ing.

A former cap­tain of Coom­babah State High School, Eva had moved to Syd­ney but pre­vi­ously worked as a re­cep­tion­ist at L.J. Hooker in Surfers Par­adise. In an im­pas­sioned Face­book post at the time of her death (since re­moved), her fam­ily wrote: “As beau­ti­ful as Evita was, in­side and out, she was filled with cer­tain in­ad­e­qua­cies … her per­fect and whole soul was not strong enough in light of a world that con­stantly bom­barded her with an ur­gency to de­mand more from her­self and her body. No woman should risk death to im­prove on per­fec­tion. To­mor­row morn­ing when you look in the mir­ror, say to your­self, ‘I am enough. I am wor­thy, I am per­fect just the way I am.’ Don’t lis­ten to a world that is hun­gry to fill your in­se­cu­ri­ties with poi­son. Stop feed­ing an in­dus­try that hates hu­mans, es­pe­cially women in the nat­u­ral state and their per­fect birth bod­ies.”

The Amer­i­can Academy of Fa­cial Plas­tic and Re­con­struc­tive Surgery (AAFPRS) – known for pre­dict­ing trends later fol­lowed in Aus­tralia – sug­gests that our ob­ses­sion with beau­ti­fy­ing the self – or with

turn­ing the “nor­mal” into the ide­alised – is gain­ing mo­men­tum. It re­ports that the “selfie” trend shows no signs of ex­pir­ing, and that “grow­ing num­bers” of peo­ple, from “teens to se­niors ”, are more cog­nisant than ever of their ap­pear­ance be­cause of so­cial me­dia, and more of them than ever are will­ing to re­sort to the knife if they don’t like what they see.

“Ex­pect an uptick in re­quests for rhino­plasty, eye­lid re­ju­ve­na­tion and neck con­tour­ing and other fa­cial plas­tic surgery pro­ce­dures,” an AAFPRS spokesman said ear­lier this year.

The lead­ing body re­spon­si­ble for the col­lec­tion of plas­tic surgery sta­tis­tics in the US, the Amer­i­can So­ci­ety of Plas­tic Sur­geons, re­ported that but­tock im­plants were among the fastest-grow­ing pro­ce­dures of 2014, up 98 per cent on the previous year. Ac­cord­ing to both the sur­geons’ so­ci­ety and AAFPRS, any stigma that once sur­rounded plas­tic surgery has van­ished as surely as bod­ily blem­ishes.

YOUNG AUS­TRALIANS HAVE GROWN UP IN

a selfie cul­ture. They’ve never known life with­out a smart­phone and cat­a­logue their pri­vate lives for pub­lic ap­praisal, with the aim of per­fect­ing the self. One 27-year-old woman I know ar­ranges her best side for ev­ery pho­to­graph, so she looks ex­actly the same in im­age af­ter im­age af­ter im­age, whether she’s on top of a moun­tain or sit­ting at a restau­rant ta­ble. In this new cul­ture of van­ity, plas­tic surgery has lost its stigma; van­ity has too.

Peo­ple are in­creas­ingly will­ing to travel over­seas for sur­gi­cal pro­ce­dures, but at what cost? Ac­cord­ing to a new Queens­land study pub­lished in the Jour­nal of Plas­tic Surgery, botched cos­metic pro­ce­dures on med­i­cal tourists are plac­ing in­creased pres­sure on Aus­tralian pub­lic hos­pi­tals. The cost of treat­ing 12 pa­tients who pre­sented to the Gold Coast Hos­pi­tal in the year end­ing June 2013 with com­pli­ca­tions fol­low­ing pro­ce­dures was more than $150,000, with the most com­mon com­pli­ca­tions be­ing in­fec­tion af­ter breast aug­men­ta­tion surgery. The report’s au­thors noted that all pa­tients had “acute com­pli­ca­tions” rang­ing from nip­ple or pe­nile necro­sis to pul­monary em­bolism.

Dr Paul Belt, a Bris­bane re­con­struc­tive and aes­thetic plas­tic sur­geon and pres­i­dent of the Queens­land chap­ter of the Aus­tralian So­ci­ety of Plas­tic Sur­geons (ASPS), sees one or two cases ev­ery week of peo­ple ad­mit­ted to hos­pi­tal be­cause of com­pli­ca­tions af­ter plas­tic surgery per­formed over­seas. “We see the whole gamut – breast aug­men­ta­tion, ab­dom­i­nal, li­po­suc­tion,” Belt says. “Of­ten pa­tients are mak­ing de­ci­sions to have surgery purely based on price con­sid­er­a­tions, and they don’t take into ac­count the cost of air­fares, hotels … which of­ten makes the price com­pa­ra­ble [to Aus­tralia] in the end. Then you have to con­sider sit­ting on a plane for eight hours im­me­di­ately fol­low­ing surgery, and the added risk of deep vein throm­bo­sis. If you have the surgery here, there’s a sur­geon avail­able for even the most mi­nor of com­pli­ca­tions.”

In Aus­tralia, sil­i­cone but­tock aug­men­ta­tions are rel­a­tively rare, and Belt has not treated a pa­tient re­turn­ing from over­seas with com­pli­ca­tions from such a pro­ce­dure. “It’s mainly an Amer­i­can thing, even though, in gen­eral, over­all global trends are re­flected in what’s hap­pen­ing here.”

In his pri­vate prac­tice Belt has no­ticed a sig­nif­i­cant in­crease in pro­ce­dures in­volv­ing “in­jecta­bles”, such as Bo­tox and fillers, to plump creases in front of the ears and hol­lows in the face. “Peo­ple are very busy and don’t want to lose time hav­ing surgery,” Belt says. “In­jecta­bles are cer­tainly in­creas­ing, [with] peo­ple want­ing Bo­tox and short­term so­lu­tions that last nine to 12 months.”

Since late last year, Medi­care has tight­ened var­i­ous re­bates on cos­metic surgery and most pro­ce­dures aren’t claimable. While Aus­tralian fig­ures for cos­metic surgery are not col­lected in a na­tional data­base, the Aus­tralasian Col­lege of Cos­metic Surgery (ACCS) es­ti­mates that ex­pen­di­ture on cos­metic sur­gi­cal and re­lated pro­ce­dures stands at more than $1 bil­lion an­nu­ally . The ACCS also says that on an an­nual ba­sis Aus­tralians have more than $350 mil­lion worth of wrin­kle re­duc­tion pro­ce­dures us­ing Bo­tulinum toxin (com­monly known as Bo­tox), 8000 breast aug­men­ta­tion surg­eries and 30,000 li­po­suc­tion pro­ce­dures.

One cos­metic pro­ce­dure no longer claimable on Medi­care is labi­aplasty, an op­er­a­tion in which the folds of skin of the vag­ina’s in­ner labia sur­round­ing the vulva are “trimmed”. The in­creas­ing pop­u­lar­ity of labi­aplasty was an agenda item of con­cern at the Aus­tralasian Sex­ual Health Con­fer­ence in Syd­ney last Oc­to­ber. Medi­care fig­ures show the num­ber of women un­der­go­ing Medi­care-billed vul­vo­plasty or labi­aplasty in­creased from 640 in 2001 to more than 1500 in 2013, a jump of 140 per cent.

“There’s been a huge ex­plo­sion in labi­aplasty in Aus­tralia,” Belt says, even though the pro­ce­dure “has ef­fec­tively ceased to be claimable since Novem­ber 2014”. He has put for­ward eight cases for Medi­care

“girls are con­sta ntly de­picted in a fairly st ereo­typ­i­cal way – most ly skinny – and men are usua lly mus­cu­lar … We are flooded with all these imag es, and there’s no­body sa ying, ‘Hold on a minute’.” PRO­FES­SOR DAVID CAS­TLE, CHAIR OF PSY­CHI­A­TRY, ST VIN­CENT’S HOS­PI­TAL, MEL­BOURNE

ap­proval and all have been re­jected. This is be­cause the Med­i­cal Ser­vices Ad­vi­sory Com­mit­tee al­tered the Medi­care Ben­e­fit Sched­ule item for labi­aplasty to pre­vent it be­ing used for cos­metic pur­poses only, and Medi­care will now only ap­prove labi­aplasty in cases of con­gen­i­tal urog­y­nae­co­log­i­cal anom­alies, fe­male gen­i­tal mu­ti­la­tion or lo­calised gi­gan­tism.

Not all labi­aplas­ties are per­formed solely for func­tional pur­poses: one of Belt’s pa­tients (who does not want her name used) said in an in­ter­view with mag­a­zine marie claire Aus­tralia that her prob­lem was largely psy­cho­log­i­cal, in that she was em­bar­rassed by her gen­i­tals. It be­gan dur­ing sex with a new boyfriend who put his hand be­tween her legs and started laugh­ing: “Wow! You’ve got a cou­ple of wiener schnitzels here!”

In re­al­ity, most of Belt’s pa­tients have the surgery af­ter ex­pe­ri­enc­ing “pain and discomfort wear­ing cer­tain types of cloth­ing, or prob­lems with hy­giene”. One woman, who also did not want to be named, told Qweekend that her surgery was “life-chang­ing”: she can now ride a bike, wear jeans, and no longer suf­fers con­stant uri­nary tract in­fec­tions. “I’ve got a level of com­fort I’d never known be­fore,” she said.

One Mel­bourne GP, Dr Mag­dalena Simonis, has grown in­creas­ingly alarmed about the ris­ing num­ber of women, par­tic­u­larly young women, seek­ing gen­i­tal surgery purely for cos­metic pur­poses. So much so that she ap­proached the Royal Aus­tralian Col­lege of Gen­eral Prac­ti­tion­ers late last year about de­vel­op­ing an in­for­ma­tion kit for GPs to deal with labi­aplasty re­quests, which has since been re­leased. Ac­cord­ing to the new guide­lines – au­thored by Dr Simonis with con­tri­bu­tions from other spe­cial­ists – fig­ures from Medi­care show the num­ber of women un­der­go­ing Medi­care-billed vul­vo­plasty or labi­aplasty in­creased from 640 cases in 2001 to more than 1500 in 2013, up 140 per cent.

The report noted that the rise in num­bers ap­peared to be a re­sponse to “chang­ing cul­tural norms” and that surgery was in­creas­ingly “be­ing sought by women who want to ei­ther feel ‘nor­mal’ or look ‘de­sir­able’”. The high­est num­ber of claims was equally dis­trib­uted be­tween three age groups: 15-24, 25-34 and 35-44 (the fig­ures don’t nec­es­sar­ily re­flect the whole pic­ture, how­ever, since many pro­ce­dures are done through pri­vate health­care or else don’t meet Medi­care re­bate cri­te­ria).

Simonis told Qweekend she de­cided to act af­ter a 17-year-old girl and her mother asked her about plas­tic surgery fol­low­ing the girl’s Brazil­ian wax treat­ment (to­tal re­moval of pu­bic hair ). The mother feared the girl’s vag­ina had pro­lapsed, but in fact her gen­i­tals were nor­mal.

Simonis sug­gests that the fash­ion for re­moval of pu­bic hair has re­vealed not only that which is nor­mally con­cealed but also wide­spread ig­no­rance about what a nor­mal vulva looks like. She says me­dia and on­line im­ages, in­clud­ing pornog­ra­phy, pro­mote the idea that women should have a “neat, sin­gle slit with noth­ing hang­ing out”.

Simonis’s ob­ser­va­tions are sup­ported by the new

study from the School of Psy­chol­ogy at Flin­ders Univer­sity, which found in its sur­vey of 351 women that those who had a greater ex­po­sure to im­ages of fe­male gen­i­tals were more likely to con­sider the pro­ce­dure. The study found 17 per cent of women aged be­tween 18 and 69 were in­ter­ested in un­der­go­ing a labi­aplasty, and that 13 per cent of women had re­ceived neg­a­tive com­ments from ro­man­tic part­ners about the ap­pear­ance of their gen­i­tals. PhD can­di­date Gemma Sharp, who con­ducted the study, says the find­ings sug­gest “a wor­ry­ing trend of women be­com­ing dis­sat­is­fied with the ap­pear­ance of their gen­i­tals. We think that if women and their part­ners were made aware of the large vari­a­tion in nor­mal gen­i­tal ap­pear­ance, this might help to al­le­vi­ate some of their con­cerns about their own gen­i­tals.”

Part of a qual­i­fied plas­tic sur­geon’s skills is al­lay­ing pa­tients’ fears and con­cerns and ed­u­cat­ing pa­tients about what is “nor­mal”, as well as dis­tin­guish­ing real psy­cho­log­i­cal need from pos­si­ble men­tal health is­sues. Dr Paul Belt says ASPS mem­bers have a min­i­mum 12 years’ med­i­cal and sur­gi­cal train­ing, in­clud­ing at least five years of spe­cial­ist post­grad­u­ate train­ing. “I’m quite happy re­fer­ring peo­ple to a psy­chol­o­gist, es­pe­cially younger peo­ple, even if I think a pa­tient doesn’t par­tic­u­larly have psy­cho­log­i­cal is­sues but may have lim­ited cop­ing skills and lim­ited so­cial sup­port; then it’s good for them to talk to some­one,” he says.

Only rarely does Belt see cases of body dys­mor­phia (a body-im­age disor­der, some­times as­so­ci­ated with anorexia, char­ac­terised by per­sis­tent pre­oc­cu­pa­tions with an imag­ined or slight de­fect in one’s ap­pear­ance). Some­times he’ll de­cide against surgery be­cause he judges a pa­tient to have un­re­al­is­tic ex­pec­ta­tions about the out­come.

Queens­land has some of the tight­est reg­u­la­tions around plas­tic surgery in Aus­tralia – it’s il­le­gal to op­er­ate on any­one un­der the age of 18 – and Belt sup­ports the Med­i­cal Board of Aus­tralia’s draft rec­om­men­da­tion to ex­tend the seven-day cool­ing off pe­riod af­ter an ini­tial con­sul­ta­tion to 14 days.

RE­AL­ITY TELE­VI­SION, SO­CIAL ME­DIA AND

a fas­ci­na­tion with celebrity all have con­trib­uted to the cul­ture of van­ity, says Queens­land Univer­sity of Tech­nol­ogy’s Pro­fes­sor Brian McNair, a me­dia re­searcher in the Cre­ative In­dus­tries fac­ulty.

“Partly, this ob­ses­sion with the self and the height­ened de­sire to ex­pose one­self in pub­lic – whether it’s the phys­i­cal body or the emo­tional self – be­gan with the ex­po­sure of so-called or­di­nary peo­ple on [re­al­ity TV] shows like Big Brother, which started in 2001,” says McNair. “We’re liv­ing in a cul­ture where peo­ple in­creas­ingly re­veal them­selves in the pub­lic do­main. So­cial me­dia – es­pe­cially Snapchat, Face­book and Instagram – have made it pos­si­ble for young peo­ple to in­stantly put up im­ages of them­selves, so we’ve got a sit­u­a­tion where or­di­nary peo­ple who are not celebri­ties can act like them be­cause tech­nol­ogy makes it pos­si­ble.” McNair says we have cre­ated a so­ci­ety with an ap­petite for want­ing to know what other peo­ple do in pri­vate. “There’s a cul­ture of emo­tional con­fes­sion go­ing on and that’s some­thing that’s partly de­vel­oped through the day­time talk show phe­nom­e­non, through pro­grams such as Oprah.”

But a con­fes­sional, celebrity-ob­sessed cul­ture isn’t all bad. Dr Hugh Bartholomeusz, newly elected pres­i­dent of the ASPS, says there are un­ex­pected ben­e­fits. “Movie stars like An­gelina Jolie high­lighted a re­ally im­por­tant prob­lem when she went pub­lic about her dou­ble mas­tec­tomy [in 2013]. It caused a lot of women to go off to their doc­tors and it did an enor­mous amount of good,” Bartholomeusz says. “The prob­lems come when some­one says they want to look like An­gelina Jolie, or X, Y or Z. Our job is to as­sess them, to look at the pro­por­tion of fa­cial con­tours, and say, yes, you’re fine as you are – is this what you re­ally want? Some­times there’s a mis­match be­tween ex­pec­ta­tion and re­al­ity.”

Pro­fes­sor David Cas­tle, Chair of Psy­chi­a­try at St Vin­cent’s Hos­pi­tal, Mel­bourne, has long been in­ter­ested in the in­flu­ence of the me­dia in what he terms “the re­lent­less pur­suit of the per­fect body im­age”. In 2007 he co-au­thored (with so­cial worker Roberta Honig­man) Liv­ing With Your Looks, in which he ar­gues that the mes­sage from the me­dia – TV, movies, mag­a­zines and the in­ter­net – is that “life is ap­par­ently bet­ter for good-look­ing peo­ple, and that only such per­fect spec­i­mens of hu­man­ity can be truly happy and suc­cess­ful”.

Cas­tle says re­al­ity shows such as Ex­treme Makeover send covert and overt mes­sages about need­ing to look a cer­tain way in or­der to be ful­filled. In his work with the St Vin­cent’s Men­tal Health Unit, which un­der­takes ed­u­ca­tional work as well as treat­ing pa­tients, Cas­tle has been sur­prised to learn how lit­tle young peo­ple recog­nise or know about im­age ma­nip­u­la­tion, such as air­brush­ing.

“We’ve been de­vel­op­ing a pack­age for kids at the hos­pi­tal,” Cas­tle says. “We try to push the fact that bod­ies and faces and ev­ery part of us have great vari­a­tions. This idea that there is an ideal form is very wor­ry­ing; you can’t un­der­es­ti­mate the im­pact and in­flu­ence of the me­dia where women and girls are con­stantly de­picted in a fairly stereo­typ­i­cal way – mostly skinny – and men are usu­ally mus­cu­lar, with a de­fined, ro­bust look. We are flooded with all these im­ages, and there’s no­body say­ing, ‘Hold on a minute’.”

Cas­tle is par­tic­u­larly ap­palled at the fash­ion for post-baby snaps, where women, of­ten celebri­ties, are feted for los­ing their preg­nancy weight within weeks. “It’s fine to get your fig­ure back, but are we re­ally say­ing that’s the most im­por­tant thing about hav­ing a baby?” The rise in “de­signer vag­ina” surgery is just another part of the alarm­ing trend pro­mot­ing uni­for­mity, he says. “We are all so glo­ri­ously dif­fer­ent. How about

be­ings?”. we start giv­ing peo­ple ideas about be­liev­ing in them­selves not based on what they look like but as whole hu­man

fa­tal er­ror … gold coast woman evita Sar­monikas died af­ter cos­metic surgery in mex­ico.

copy catch … plas­tic sur­geon dr paul belt: global trends are re­flected lo­cally.

bot­tom line … KIM KAR­DASHIAN’s curves are a tem­plate for COS­METIC SURGERY.

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