Un­der the Knife, un­der the radar

Soar­ing de­mand for pret­tier faces has cre­ated a large un­der­ground mar­ket for cos­metic surgery – what’s known in China as med­i­cal cos­me­tol­ogy. But many of the ‘sur­geons’ have no pro­fes­sional qual­i­fi­ca­tions, and leave cus­tomers mu­ti­lated and scarred

NewsChina - - COVER STORY - By Qian Wei

Yang Jin­wen's de­ci­sion to un­dergo cos­metic surgery at her reg­u­lar hair sa­lon must have seemed like a good deal at the time – but it left her nose rot­ting on her face. A beau­ti­cian con­vinced the Shang­hai woman, who had long de­sired a higher nose which is con­sid­ered a sign of beauty in China, to have her face in­jected with a type of acid used in facelifts. Soon af­ter the pro­ce­dure, Yang no­ticed the in­jected area was bleached white.

When she asked, the sa­lon told Yang this was a nor­mal re­ac­tion to the pro­ce­dure, and that her nose would heal af­ter sev­eral days. But when the pain be­came too much to bear, Yang rushed to hos­pi­tal, where a pro­fes­sional plas­tic sur­geon told her that her nose had been dis­fig­ured.

“It was dis­col­ored and had started to rot from the in­side when I saw her,” the sur­geon, Wang Ji­geng, told Newschina. “We had to do an op­er­a­tion to cut open her nose and get the in­jected ma­te­rial out. But since the in­jec­tion had al­ready pen­e­trated into the nose tis­sue, the op­er­a­tion could not avoid im­pact­ing her ap­pear­ance,” Wang said.

Wang con­cluded that who­ever ad­min­is­tered the in­jec­tion had wrongly in­jected it into her blood­stream through a nose cap­il­lary, in­stead of into the tis­sue.

Yang's op­er­a­tion went smoothly but left her a large, ob­vi­ous scar on her nose which would not fade for a year. The ma­jor op­er­a­tion re­quired Yang to take plenty of bed rest, and she ul­ti­mately lost her job at a large bank. Yang has suf­fered from de­pres­sion and anx­i­ety since the in­ci­dent.

She's not alone. Nu­mer­ous me­dia re­ports have re­vealed women be­ing dis­fig­ured as a re­sult of un­der­ground cos­metic surgery. Experts say few cus­tomers are aware that a range of cos­metic pro­ce­dures, in­clud­ing many that don't in­volve a sur­geon's scalpel, con­sti­tute med­i­cal treat­ment and should only be per­formed by a

licensed doc­tor at a licensed hos­pi­tal or clinic. “We have too many un­der­ground cos­metic clin­ics and sa­lons,” said Wang. “Too many.”

Alarm­ing Rise

Wang, who grad­u­ated from a mil­i­tary med­i­cal uni­ver­sity of the Peo­ple's Lib­er­a­tion Army in 1984 and has been en­gaged in plas­tic surgery for more than 30 years, says med­i­cal cos­me­tol­ogy is ex­pand­ing at an alarm­ing rate. This unique Chi­nese term refers to all med­i­cal means, in­clud­ing med­i­ca­tion, surgery and in­jec­tions, em­ployed to im­prove one's ap­pear­ance.

“When I grad­u­ated, there were few ded­i­cated hos­pi­tals and those who worked in the plas­tic surgery de­part­ments of big, pub­lic hos­pi­tals only took pa­tients who had been dis­fig­ured in ac­ci­dents or dis­as­ters,” Wang said.

“Few thought that plas­tic surgery should be done on healthy peo­ple. Plas­tic sur­geons were looked down upon by other sur­geons at that time,” he added.

Wang sees the growth of the in­dus­try as a re­sult of China's re­form and open­ing-up, which got in full swing in 1992 when Deng Xiaop­ing, dur­ing his South­ern Tour, em­pha­sized in a speech that mar­ke­ti­za­tion was not the es­sen­tial dif­fer­ence be­tween cap­i­tal­ism and so­cial­ism, and en­cour­aged the Chi­nese econ­omy to more ag­gres­sively open up.

Pri­vate busi­nesses sprang up like mushrooms and gov­ern­ment or­gans also tried to get a piece of the pie. In the year of Deng's speech, Bei­jing-based Huangsi Plas­tic Surgery Hos­pi­tal, the first hos­pi­tal Wang worked at, es­tab­lished a cos­metic clinic and saw crowds of peo­ple queu­ing for ap­point­ments. “It's my turn! It's my turn!” rang out across the clinic each day, Wang re­called, and at peak times, he per­formed more than 30 cos­metic pro­ce­dures in a day.

“Pub­lic hos­pi­tals and clin­ics do not usu­ally serve healthy peo­ple, so med­i­cal cos­me­tol­ogy emerged to fill the gap. Given so­cial med­i­cal in­sur­ance did not cover it, there was a lot of space for com­mer­cial­iza­tion from the very be­gin­ning.”

In 2000, Wu Jian­wei, a busi­ness­man from Pu­tian, Fu­jian Prov­ince, set up China's first pri­vate cos­metic clinic and made a pot of money from the in­tro­duc­tion of Amazin­gel, an in­jec­tion used mostly for surgery-free breast en­hance­ments. “Amazin­gel sold for 25 yuan (US$3.9) per mil­li­liter then, and a breast en­hance­ment needed sev­eral hun­dred milliliters,” Wang re­called.

Wu's for­tune at­tracted floods of en­thu­si­asts and be­fore long Pu­tian was a med­i­cal cos­me­tol­ogy hub. Although Amazin­gel was later re­vealed to have ter­ri­ble side ef­fects, in­clud­ing caus­ing in­flam­ma­tion and even de­for­mi­ties, and was banned by the gov­ern­ment, the med­i­cal cos­me­tol­ogy craze did not abate. In­stead the avail­able pro­ce­dures ad­vanced and diver­si­fied. Ac­cord­ing to a 2017 re­port by Soy­oung, a pop­u­lar Chi­nese med­i­cal cos­me­tol­ogy App de­scribed as a plas­tic surgery mar­ket­place, the in­dus­try has grown an as­tound­ing 40 per­cent each year since 2015, much higher than the global av­er­age of seven per­cent. A re­port is­sued the same year by US phar­ma­ceu­ti­cal com­pany Al­ler­gan found Chi­nese women's monthly spend­ing on med­i­cal cos­me­tol­ogy had dou­bled the global av­er­age level, and the China As­so­ci­a­tion of Plas­tics and Aes­thet­ics once pre­dicted that China's med­i­cal cos­me­tol­ogy in­dus­try would ex­pand to be the world's third largest – val­ued at around 800 bil­lion yuan (US$123.1B) – by 2019.

Prac­tic­ing on Chick­ens

The rapid ex­pan­sion is said to be in part due to Wu Jian­wei's trou­bling in­no­va­tion – the po­si­tion of the “cos­metic con­sul­tant.” At first, those seek­ing med­i­cal cos­me­tol­ogy were re­ceived by the doc­tors who would per­form their surgery. For pro­fes­sional li­a­bil­ity rea­sons they tended to lay out the risks, which in­evitably scared many cus­tomers away. “Cos­metic con­sul­tants” thus came to take over the re­cep­tion work – dif­fer­ent from sur­geons, they treat med­i­cal cos­me­tol­ogy as an or­di­nary prod­uct to be sold, and tend to ex­ag­ger­ate its ef­fects while

hold­ing back on po­ten­tial risks and side ef­fects.

“Med­i­cal cos­me­tol­ogy is a kind of med­i­cal treat­ment, and all med­i­cal treat­ment has risks,” Wang said. “For ex­am­ple, in­ject­ing acid into blood ves­sels can cause tis­sue in­jury and even blind­ness. One side-ef­fect of dou­ble eye­lid surgery is chron­i­cally dry eyes, and in ex­treme cases pa­tients may be un­able to close their eyes. Mean­while li­po­suc­tion can cause car­dio­vas­cu­lar dis­ease.”

How­ever, as these so-called con­sul­tants de­lib­er­ately hide the risks, many cus­tomers are mis­led and think med­i­cal cos­me­tol­ogy, espe­cially seem­ingly mi­nor pro­ce­dures, are risk-free and safe. That all changes when they find them­selves dis­fig­ured and forced to re­pair their faces at a proper hos­pi­tal.

Jin Qi, who works in a plas­tic surgery de­part­ment at a Bei­jing­based pub­lic hos­pi­tal, told Newschina that one-third of his pa­tients were in for these re­pairs – whether for restor­ing func­tion or im­prov­ing cos­metic ef­fects.

Wang and Jin both claim cos­metic mal­prac­tice re­mains at a low rate – much lower than or­di­nary med­i­cal mal­prac­tice – but unlicensed clin­ics and sur­geons have con­trib­uted to a rise in in­ci­dents.

“Dur­ing my time at Huangsi Plas­tic Surgery Hos­pi­tal, I saw many doc­tors from other de­part­ments shift to med­i­cal cos­me­tol­ogy, many of whom were even older than me,” Wang told Newschina.

Experts say a pro­fes­sional plas­tic sur­geon should have at least 10 years' train­ing be­fore they can in­de­pen­dently per­form cos­metic surgery. Unlicensed ones typ­i­cally re­ceive 10-15 days of train­ing and are said to prac­tice their skills on chick­ens.

Worse, as the ac­tual num­ber of licensed cos­metic sur­geons falls far short of de­mand, many clin­ics se­cretly rent pro­fes­sional li­censes from real sur­geons to meet the re­quire­ment of ap­ply­ing for a busi­ness li­cense. This means the ac­tual num­ber of licensed, pro­fes­sional cos­metic clin­ics is even lower than of­fi­cial sta­tis­tics sug­gest. All of these have in­creased the risks of dodgy med­i­cal cos­me­tol­ogy. A 2015 re­port by The Mir­ror, a Bei­jing-based le­gal pa­per, re­vealed that in the past 10 years when the sec­tor was grow­ing rapidly, cus­tomer com­plaints about failed med­i­cal cos­me­tol­ogy to­taled 200,000 – mean­ing 20,000 Chi­nese peo­ple were dis­fig­ured or wronged by med­i­cal cos­me­tol­o­gists every year.

Ir­ra­tional Ex­pec­ta­tions

Ac­cord­ing to Wang, a pro­fes­sional sur­geon is li­able to refuse ex­ces­sive or un­work­able de­mands from cus­tomers, but many sur­geons have been swept up in the pur­suit of prof­its. “Few would shake their head in the face of money, espe­cially given the pres­sure to per­form... and cus­tomers can sim­ply turn to other sur­geons if one re­fuses them,” Wang said.

Li Zhan­qiang, a plas­tic sur­geon who works at the same hos­pi­tal as Jin Qi, echoed the sen­ti­ment. He said most cus­tomers are so de­ter­mined to be­come more beau­ti­ful that they will not give up eas­ily. “This group of peo­ple are gen­er­ally hy­per­crit­i­cal and place high de­mands on them­selves... They have ir­ra­tional ex­pec­ta­tions of med­i­cal cos­me­tol­ogy, think­ing it will trans­form them into [Chi­nese su­per­stars] Huang Xiaom­ing or An­ge­lababy af­ter one small pro­ce­dure. It's im­pos­si­ble,” he said.

On his pub­lic Wechat ac­count, Li once listed 10 sins of those who ex­pect too much of med­i­cal cos­me­tol­ogy. They in­clude be­ing con­ceited, skep­ti­cal, greedy, un­re­al­is­tic, and ea­ger for quick suc­cess.

“Med­i­cal cos­me­tol­ogy is ac­tu­ally against na­ture,” Li wrote on his Wechat pub­lic ac­count. “You pay for go­ing against the na­ture – not just with money, but in pain, scars and var­i­ous pos­si­ble long-term con­di­tions brought about by pro­ce­dures.”

Li Bin, pres­i­dent of Beau­care Clin­ics, a large Chi­nese med­i­cal cos­metic chain-clinic, how­ever, has a dif­fer­ent point of view. “Cos­metic sur­geons should be pro­fes­sional and ex­pe­ri­enced enough to tell which are the cus­tomers with ex­ces­sive de­mands,” he said.

“Is­sues sel­dom arise at licensed clin­ics, as the sur­geons com­mu­ni­cate with cus­tomers about their de­mands, psy­chol­ogy and the pur­pose of the surgery. Seen from this an­gle, cos­metic con­sul­tants are un­re­li­able and cos­metic clin­ics should bear full re­spon­si­bil­ity for fail­ures and surg­eries gone bad,” he told Newschina, adding that overtreat­ment is ram­pant in the in­dus­try where many clin­ics coax cus­tomers into un­der­go­ing un­nec­es­sary treat­ments or al­ter­ing their faces sig­nif­i­cantly, re­gard­less of the po­ten­tial risks.

Cus­tomer ed­u­ca­tion is Wang's so­lu­tion to the cur­rent cri­sis in med­i­cal cos­me­tol­ogy. “It should be pub­li­cized that even mi­nor pro­ce­dures that do not need a scalpel, such as in­jec­tions and pho­tore­ju­ve­na­tion, are po­ten­tially risky and should al­ways be per­formed by a licensed sur­geon at a licensed clinic. No mat­ter who works the re­cep­tion, pa­tients should have a clear idea about who is go­ing to per­form surgery on them,” he said.

“Peo­ple tend to find an ex­pe­ri­enced and rep­utable doc­tor when they have a dis­ease, but when it comes to med­i­cal cos­me­tol­ogy they care more about price. Med­i­cal cos­me­tol­ogy is not an ev­ery­day prod­uct, but one in need of a set of med­i­cal so­lu­tions,” he added.

Poor Reg­u­la­tion

Guo Shuzhong, di­rec­tor of the Plas­tic Surgery As­so­ci­a­tion un­der the Chi­nese Med­i­cal As­so­ci­a­tion, says the ab­nor­mal de­vel­op­ment of the Chi­nese med­i­cal cos­me­tol­ogy mar­ket is part of the prob­lem.

“The mar­ket is over­heated,” he told Newschina, “In­vest­ment is pour­ing in, even if only one-third of pri­vate clin­ics are ac­tu­ally mak­ing money.”

A lead­ing cause of such low re­turns is be­lieved to be the high cost of ad­ver­tis­ing, espe­cially on China's big­gest search en­gine Baidu, which has been crit­i­cized for tak­ing pay­ments from com­pa­nies to in­crease their search rank­ings.

Baidu was listed fourth in ad­ver­tis­ing rev­enue in Zenith Me­dia's Top 30 Global Me­dia Own­ers for 2017, with med­i­cal cos­me­tol­ogy rep­re­sent­ing a large por­tion of its tak­ings.

A 2017 re­port by Caixin, a Chi­nese fi­nan­cial mag­a­zine, cited a study by Gu­osen Se­cu­ri­ties which found mar­ket­ing took up 50 per­cent of the to­tal cost of med­i­cal cos­me­tol­ogy, with clin­ics spend­ing on av­er­age 6,000 yuan (US$923) to at­tract each cus­tomer. Although a batch of med­i­cal cos­me­tol­ogy apps have emerged in re­cent years, the search mogul Baidu still plays a de­ci­sive role.

In re­al­ity, apps have fur­ther in­creased com­pe­ti­tion, be­com­ing yet an­other plat­form for ad­ver­tis­ing med­i­cal cos­me­tol­ogy. Many peo­ple, some al­legedly em­ployed by cos­metic clin­ics, post their pho­tos be­fore and af­ter pro­ce­dures, lur­ing more cus­tomers to go un­der the knife, and to pay more at­ten­tion to their ap­pear­ance. Med­i­cal cos­me­tol­ogy is now so com­mon that many live-stream­ing stars have their faces sur­gi­cally al­tered be­fore they sit down in front of their we­b­cams.

“Mer­can­til­ism has cre­ated a money-wor­ship­ping so­ci­ety where good-look­ing peo­ple are more pop­u­lar, gain ad­van­tages and make money... With such fierce so­cial com­pe­ti­tion, many hope they will im­prove their prospects by im­prov­ing their ap­pear­ance,” Guo said.

How­ever, the Chi­nese gov­ern­ment has been caught off guard by the bur­geon­ing de­mand for cos­metic pro­ce­dures. Ac­cord­ing to a 2017 re­port by Geng­mei (lit­er­ally, more beau­ti­ful), an­other Chi­nese med­i­cal cos­me­tol­ogy app, only 9,500 clin­ics in China have li­censes – about one-sixth of the es­ti­mated num­ber of clin­ics. Hid­ing in beauty sa­lons and even homes, the unlicensed ones are thought to see around two and a half times as many cus­tomers as licensed ones, and em­ploy around 150,000 unlicensed sur­geons.

In May 2017, six gov­ern­ment de­part­ments launched a joint crack­down on unlicensed cos­metic clin­ics and sur­geons, but the pun­ish­ments meted out were a soft touch. Typ­i­cally, sur­gi­cal in­stru­ments were con­fis­cated and com­pa­nies fined no more than 20,000 yuan (US$3,100). This did lit­tle to dent the growth of unlicensed clin­ics.

“We have to tighten up the pun­ish­ments,” Guo em­pha­sized dur­ing the in­ter­view. “The un­der­ground mar­ket can be reg­u­lated if the rel­e­vant de­part­ments want to do so.”

Ac­cord­ing to Guo, China has a num­ber of large, high-qual­ity licensed cos­metic clin­ics and many, like Li Bin's, hope to fight the in­dus­try's rep­u­ta­tion for put­ting prof­its above peo­ple. How­ever, with the gov­ern­ment miss­ing in ac­tion on guid­ance and man­age­ment, these ef­forts will likely be too weak to reign in the chaos.

Women with a sim­i­lar in­ter­net celebrity face at an an­niver­sary cel­e­bra­tion of a bar in Taiyuan, Shanxi Prov­ince, Au­gust 28, 2016

A young woman from Shan­dong Prov­ince live-broad­casts her rhino­plasty in Bei­jing to crowd­fund money for the pro­ce­dure

Cus­toms of­fi­cers in Shen­zhen, Guang­dong Prov­ince, show off smug­gled cos­metic surgery in­jec­tions, Oc­to­ber 29, 2015

A 19-year-old girl in Qing­dao, Shan­dong Prov­ince, pre­pares for her plas­tic surgery which she hopes will make her look like Chi­nese ac­tress Liu Yifei

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