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Clay illustration by Lily Offit; Photographed by Ben Denzer
Annie Jin and Ian Whittall
University of Connecticut School of Medicine, Farmington, CT, 06032
Correspondence should be addressed to Annie Jin and Ian Whittall at ajin@uchc.edu and whittall@uchc.edu
ABSTRACT
With increasing globalization in communication, travel, economics, and innovation, medicine and plastic surgery have also made great advancements. The following essay looks at plastic surgery in South Korea, and the innovations South Korean plastic surgeons have made in the field. We explore the cultural, societal, and economic influences that may have impacted the development and popularity of plastic surgery in South Korea, and the rise of South Korean medical tourism. We also compare South Korean plastic surgery versus American plastic surgery, showing differences and similarities in procedures performed, costs, and in patient demographics. Additionally, we look at the possible impacts of plastic surgery on mental health. Finally, we conclude with a discussion that highlights the importance and incredible potential of cross-cultural communication and collaboration for the prospective advancements that we, in America, could learn, adopt, and create.
A LOOK AT SOUTH KOREAN PLASTIC SURGERY
Sometimes called the “Cosmetic Surgery Capital of the World,” South Korea currently performs 24% of all cosmetic surgeries [1]. South Korea’s ethno-historical context, societal pressures, economic opportunities, and cultural beliefs have all contributed to the popularity and growth in this field.
Historical and Cultural Context of Plastic Surgery in South Korea
The historical pretext within which medicine developed across the world is diverse and unique for each nation. One concept pertinent to aesthetics and contours that predates modern medical practices is facial physiognomy: the belief that a person’s facial features can determine his or her personality, fortune, past, present and future. Although this belief has become less influential in more recent generations, it is still widely recognized by older people of several cultures, including South Korea, where there are still physiognomy specialists who practice this craft [1]. It is through this cultural context that some South Korean plastic surgeons report the plastic surgery boom was born, as even the most subtle changes can change a person’s life according to physiognomy [2]. Additionally, it may explain why 20% of South Koreans have cited parental influence as the reason why they went under the knife [3]. In 2020, Reuters estimated the South Korean plastic surgery industry to be worth $10.7 billion [4].
During the Asian Financial Crisis of 1997, the unemployment rate rose from 2.61% to 6.8%. Approximately 1 million technicians and unskilled workers lost their jobs and were the most severely affected groups of individuals [5]. In South Korea, job applicants have traditionally been required to include a photo of themselves in applications; one study found that 80% of job recruiters in South Korea cited that physical appearance was an important factor in screening candidates [1]. In another study, the majority of male and female applicants both indicated that they believed attractiveness was a crucial factor in seeking various job During the Asian Financial Crisis of 1997, the unemployment rate rose from 2.61% to 6.8%. Approximately 1 million technicians and unskilled workers lost their jobs and were the most severely affected groups of individuals [5]. In South Korea, job applicants have traditionally been required to include a photo of themselves in applications; one study found that 80% of job recruiters in South Korea cited that physical appearance was an important factor in screening candidates [1]. In another study, the majority of male and female applicants both indicated that they believed attractiveness was a crucial factor in seeking various job opportunities [3]. Consequently, the Asian Financial Crisis resulted in many patients flocking to plastic surgery as job opportunities became scarce and workplace competition increased1. Thus, despite its cost, plastic surgery was and is still seen as a potential way out of unemployment that pays for itself [3].
As the number of plastic surgeries performed in South Korea increased due to the economic instability, an interesting trend in the demographic of people seeking plastic surgery emerged. Currently, the majority of South Koreans receiving plastic surgery are 20 to 40 years-old [6]. The average age of first plastic surgery procedure is 21.8 years-old7, and up to 46% of female college students in South Korea have had experience with cosmetic procedures [6]. Plastic surgery has even become a common graduation gift for many individuals [1,8]. This is in contrast to the US, where the largest age demographic receiving plastic surgery is 35 to 50 years-old [9].
Comparison of Plastic Surgery Procedures in the United States vs. South Korea
Although the United States and South Korea have different historical and cultural contexts for plastic surgery, both countries show similar patterns in the most frequently performed plastic surgery procedures. Noninvasive procedures such as botulinum toxin and hyaluronic acid chemical peels are the most common procedures that are performed, overall. Breast augmentation, lipoplasty, blepharoplasty and rhinoplasty are the most common invasive procedures. However, breast augmentation is more common in the United States, while lipoplasty and blepharoplasty are more common in South Korea. It has been suggested that these differences may be the manifestation of differences in cultural beauty standards [10-11].
New and Popular Innovations in South Korean Plastic Surgery
Since plastic surgery’s rise in popularity, South Korea has become a leader in new cutting edge innovations in the field. These innovations have largely been driven by the demand for certain qualities that are ascribed to beauty and success in South Korea. While not surprising, restoration and maintenance of youthful-appearing skin is one such feature. Innovative, noninvasive modalities include stem cell treatments, which aid with collagen remodeling and architecture to improve skin elasticity, and machines, such as the Ultraformer 3 HIFU and Ulthera, which thermodynamically induce collagen fiber contraction via high-intensity, focused ultrasonography to achieve skin tightening [12] Aegyo sal, translated as “eye smiles,” is a widely popular surgery that is rather unique to South Korea in which fat grafting and injection under the eyes is performed to give a more youthful appearance [13].
Another desirable feature in South Korea is a small face and jaw, which has led to the popularity of previously less-practiced facial contouring techniques, as well as advancements. A popular surgery that achieves this small face-and-jaw look is called the V line surgery, a type of mandibuloplasty that originated from surgeries used to treat severe congenital deformities. The procedure involves the use of oscillating saws that shave the mandible and may involve the intentional breaking and realignment of the bone [13]. Zygoma reduction is another common approach to narrowing the face in South Korea that is not routinely performed in the US outside of transgender facial feminization procedures. In order to reduce operative time and postoperative edema, South Korean plastic surgeons have developed a new minimally invasive technique for this procedure in which the surgery is performed through a single 5 mm intraoral stab incision on each side. This approach has also been shown to reduce complications such as cheek drooping, facial nerve injury, temporomandibular joint injury and malunion. Results are also more drastic in comparison to traditional methods, and patients can resume daily life within 3 days of the operation [14].
Finally, large eyes with double eyelids are also seen as desirable. The minimally invasive 3point subcutaneous tunneling method for blepharoplasty has become popularized in several Asian countries including South Korea, which has been shown to reduce complications such as swelling, congestion, post-operative pain in comparison to the traditional methods of upper blepharoplasty with tarsal fixation. Further benefits include a reduced rate of reversion of double eyelids back into monolids [15]. Another uniquely South Korean technique for double-lid blepharoplasties that has been recently developed is septoaponeurosis junctional thickening, which has been reported to create a more dynamic and natural double eyelid fold. One high-volume study of the technique followed over 900 patients and found that 95% of patients reported satisfaction 2 to 8 years following the surgery [16].
The Costs and Rise of Medical Tourism in South Korea
In addition to improved cosmesis and decreased complications, some procedures that have been popularized or pioneered in South Korea may be more affordable in comparison to similar procedures in the US. For example, a reconstructive rhinoplasty in the United States usually uses a cartilage autograft and would often cost an average of $8,000. However, in South Korea, reconstructive rhinoplasties typically use silicone allografts instead of autografts and only cost $5,000. The most apparent benefit of silicone allografts over autografts is decreased donor site morbidity, as the cartilage autografts are taken from the patient’s own ribs or auricular tissue, in addition to quicker recovery. Decades of experience with silicone allografts have also demonstrated that they may also have a better long-term safety profile and reduced risk of infection and displacement in comparison to traditional allografts [17-18].
The large supply and ease of access to plastic surgery in South Korea may also be partially responsible for the affordable pricing of many plastic surgery procedures. There is a higher percentage of plastic surgeons among South Korean doctors than any other country. In fact, according to 20182019 data, the proportion of plastic surgeons to all doctors in South Korea was 2.6%, while in the US it was 0.7% [1,19]. Notably, one district in Seoul, Gangnam, has even been termed the “Beauty Belt”' as it has between 400 and 500 clinics and hospitals that offer cosmetic procedures and surgeries [20]. Such a high saturation of supply in the market may drive prices down. The price of a rhinoplasty at 1 of the top 5 hospitals in South Korea can cost between $2000-3520, while a facelift ranges between $7000-11,500, and an upper blepharoplasty can cost as little as $2000. In comparison, a rhinoplasty in Beverly Hills would cost on average $7,475, a facelift would cost on average $12,125, and upper blepharoplasty would cost between $4,000-$6,000 [21-22].
This affordable pricing for high-quality procedures is thought to be one of the primary causes of growth in South Korea’s medical tourism industry. In 2009, South Korean medical tourism was only attracting 60,000 foreign patients every year, but by 2017, 320,000 patients were foreigners. Currently, foreign patients make up 40 to 50% of all plastic surgeries performed in South Korea [23]. Most of these patients come from countries such as Japan and China, which is thought to be attributed to the high quality and affordable pricing associated with South Korean plastic surgery [7]. Based on the number and types of procedures performed per 1000 population, one study in The Economist reports that the South Korean plastic surgery industry has a 1.7 times higher procedure per capita rate than that in Taiwan, 6.9 times higher than in Thailand, and 17 times higher than that in mainland China [20].
Critics on Plastic Surgery
While so far this article has described the accomplishments and features of South Korean plastic surgery that other countries should borrow from or model after, some critics may argue that the normalization of plastic surgery and ease-of-access may contribute to and perpetuate increasingly higher beauty standards that may ultimately be detrimental for mental health [24-25]. Additionally, there could be other underlying reasons motivating people to have plastic aesthetic or cosmetic procedures that may be perpetually left unaddressed. As one BBC article stated, “according to seven epidemiological studies, women who undergo breast enlargement have a suicide rate at two or three times that of the general population. Presumably there is an underlying dissatisfaction which makes some people resort to breast surgery and which the surgery does not solve… [such as] body dysmorphia disorder” [26]. However, our appearances, the subtle contours, wrinkles, scars, and tattoos, all carry our history. They tell each of our stories at just a glance to even the most distant of strangers. For some people, there are outward-facing aspects of their story that hinder them, mentally or physically. Ultimately, plastic surgeons are uniquely responsible for allowing people to change these stories that people wear for the better. So, whether these changes manifest through form or function, they often re-affirm patients’ identities and self-concept in ways that improve their well-being [27].
CONCLUSION
It is evident that plastic surgery in South Korea may possess several techniques and other features that plastic surgeons in the US may benefit from adopting. This scenario exemplifies the great potential for sharing and collaborating with physicians across the world on new treatment methods, surgical techniques, and other medical advancements. Doing so could lead to new innovations and improvements in medicine at home and abroad. By creating global partnerships and networks, such as through international rotations during residency, we would facilitate the spread of knowledge and resources and achieve more than what an independent institution or country could achieve alone. Such collaboration could vastly improve health care equity and help speed research advancements by making the most up-to-date medical knowledge and care more easily accessible. By doing so, we can ensure that we provide our future patients with the best treatment options and outcomes in the world, even if they do not travel to South Korea for their blepharoplasties.
POTENTIAL CONFLICTS OF INTEREST
None.
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