Domestic and foreign clinics are competing to nip and tuck China's middle class, especially now that local men want to look good, too

----By Mark Godfrey

It all started with Hao Lulu. Billed as "China's first man-made beauty", the 18-year-old Beijing student spent RMB110,000 on breast and buttocks enlargements to give herself an edge on China's beauty pageant circuit. She became a celebrity, and a staple at Miss Plastic Surgery pageants around the country. But the sum she'd paid - much more than a year's earnings for most Chinese - irked authorities justifiably keen on a more equitable society, and Miss Plastic Surgery competitions no longer make prime time on Chinese television.

But Hao Lulu's enhanced curves have opened the sluice gates. The Plastic Aesthetics and Laser Medical Center at Beijing Zhongguancun Hospital, a large public hospital in Beijing's university district, where Hao had most of her surgery done, has seen more than 400 patients since it opened in August 2005. Most customers are opting for a quick nip and tuck with laser equipment, says Dr Su Mingshan, dean of the aesthetics department at Zhonguangcun Hospital. Welcoming patients in a separate reception room off the hospital's noisy lobby, with framed photos of Hao Lulu grinning gratefully from the walls, Su boasts of cutting-edge laser machines shipped from Switzerland and the USA to meet a demand for laser surgery.

Grafting a shuang yan pi, the double eyelid seen as a sign of beauty by many Chinese, is an easy half-hour operation. A more complex face realignment can take two hours. Other patients who come in for "comprehensive operations" have body fat trimmed in five-hour sessions under the knife. Fat loss procedures have become very popular, says Dr Su. "Chinese ladies always want to be thinner. You see the results immediately, and it's very hard to gain that weight back because we destroy the cells."

Male vanity

Surgical advances such as better botox and safer liposuction have been driving a trend among Chinese patients for "less invasive, discreet surgery", says Dr Michael Gabriel, whose Confidant clinic in Beijing has been seeing patients since May 2005. Like Zhongguancun Hospital but located in an office tower in the city's business district, Confidant Medical Services sees locals for nose and chin surgery as well as eye revisions. Plastic surgery has been popular with Chinese women for at least a decade, says Gabriel, an American doctor and director of Confidant.

Larger incomes and a greater emphasis on work and promotion have been drivers for Confidant's business too. Dr Su puts his Zhongguancun clinic's good fortune down to middle-class prosperity of the sort flaunted by Hao Lulu. "It's because there's money around and you need a place to consume it."

Four full-time surgeons see patients seven days a week. Cutting a double eyelid costs from RMB1,500 to RMB2,000 while a face restructuring or breast enhancement costs up to RMB30,000. Price is no problem for patients and return customers make up much of the business. "Some people get addicted to it," chuckles Su. The vanity and wealth prized by ancient Chinese culture helps too, he adds. "There's a Chinese tradition that gentlemen should pay more attention to their clothes. So today they're wearing brands."

Catering to male vanity is part of the business plan at Confidant, which hires two full-time American physicians and three full-time nurses. A nose restructuring at Confidant costs RMB5,000, and the double eyelid procedure RMB3,000. Prices for a facelift at the clinic average at RMB18,000, and a breast enlargement operation costs RMB15,000. Over US$1 million went into opening the clinic, which offers primary care and plastic surgery under one roof. The bet is both will complement each other, especially among male patients. "Cosmetic surgery can be a long-term adjunct to enhance the quality of patients' lives, so we strive to establish both our primary care and cosmetic patients as long-term patients and there has been a synergy between these two," says Gabriel.

Obesity and stress worry male expatriates, while Chinese men come in for help with chronic conditions like diabetes, asthma, and hypertension, Gabriel explains. Both seek care for erectile dysfunction. Client lists at both clinics break down 70-30 percent between men and women - "but we have seen a trend to parity," adds Gabriel, putting his success in drawing male patients down to a trend in cosmetic surgery towards "minimally invasive procedures that are affordable, require little or no downtime, and have very little potential risk".

Hence men come in to fix for obesity and diabetes and stay to ease wrinkles and dissolve double-chins. Others opt for laser hair removal. "They want minimal-downtime liposuction for excessive belly fat, and medications for hair loss," explains Gabriel. Beijing men are, however, slower to see a plastic surgeon compared to more worldly counterparts in the south of the country, says Dr Su Mingshan. "While I was in the south, many men came to me for face restructuring and nose jobs." Most of his local male customers come for fat removal.

While Dr Su runs a profitable clinic in a state-owned hospital, Gabriel was drawn by China's loosening of laws regulating private clinics. There has been significant recent investment, and many new private ventures like physical examination centers and "international clinics", says Gabriel, who had been running an impotence clinic in Beijing since 1998, using local physicians. They took his concept and began competing against him.

Now registered as a wholly foreign-owned enterprise, Gabriel also sees the recent flood of expatriates into Beijing as a growing and untapped market. Doctors Gabriel and Su would like more of each other's patients. Only eight of Su's 400 clients so far have been foreigners - and those were overseas Chinese. "We'd love to get more foreigners, but since tight government regulations restrict advertising it's hard."

Only 15 percent of Confidant's customers are local Chinese - the rest are expatriates - but ironically, more direct advertising in local media has increased the number of local Chinese who come seeking cosmetic services - "especially correction of poor cosmetic work".

Improved practices

Dishonesty has given plastic surgeons a bad name in China, where beauty pageants aside, local TV viewers have become used to seeing horror cases of faulty plastic surgery. But rigid government rules make licenses hard to come by for the private hospitals. Surgeons, Dr Su explains, must have at least five years' experience in state hospitals before being granted a license. And besides, most plastic surgery procedures are not as risky as people think. "We've done more than 400 operations and there's been no accidents."

Locals come to Confidant for quality, says Gabriel. "We recommend reasonable interventions and bring the latest techniques and best materials to the table during free consultations with a surgeon." Beijing is "awash" with cosmetic clinics using phony medications and "deceptively credentialed surgeons" to do their surgery, says Gabriel. Poor hygiene and dishonesty are prevalent, he adds. "There is no longstanding tradition or expectation that your doctor will have your best interests at heart."

Being profitable within three months of opening has allowed Confidant China to put reputation over earnings. "We never push too hard for surgery ... Preserving reputation and producing happy patients that look good is more of a priority than squeezing the next patient for all that we can."

They may be eating into his customer base but Dr Su Mingshan welcomes foreign competition. "Their arrival will help develop the industry in China. What's more, we think Chinese doctors' skills are as good as Western doctors. We used to think Korean doctors were better, but we have met many Koreans and we are better than them. The more cases you deal with the better you get, and China has a huge population!"

Chinese surgeons have become more honest too, says Dr Su. "In the past, Chinese people thought Western people had higher noses and ears and wanted them. Now surgeons are professional and will tell them that this doesn't suit Asian face structures." The clamp down following the waves of publicity generated by Hao Lulu and others was unfair, says Su. "Most media reports about hospitals are negative. They concentrate on ordinary people's complaints about the expense of hospitals and the unreliability of doctors."

Confidant plans to expand beyond its Beijing clinic, with eyes on Shanghai for a second clinic opening. Advertising as an experienced and honest American physician is an advantage in drawing business, he's found. But it's also been a disadvantage in expanding the clinic. "It is simply too costly to pay the required salary to attract good American physicians, as well as pay their expected living and family expenses."

Back at Zhongguancun Dr Su is ready to welcome customers new and familiar. Buoyed by the many promotional miles out of cause c¨Śl¨¨bre Hao Lulu - her photo adorns even the paper bags at the clinic - the state-owned hospital will shortly take delivery of the best laser equipment the market can offer, flown in from Israel. Su is on familiar terms with some of Beijing's household names. Neither money nor age are barriers for them, he says. "Some ladies older than 70 keep coming!"

Cutting-edge generation

Until the early 1980s, cosmetic surgery was outlawed in China, labelled a bourgeois vice. Perhaps not by accident, the young people born just after that period are now the country's most prolific body-enhancing group. According to a 2005 survey by China Central Television (CCTV) in Beijing, Shanghai and Chongqing, over 40 percent of those going under a plastic surgeon's knife are university students and 30 percent of them are still in high school. They are likely not rebelliously saving their own money for a secret operation, either - a survey conducted by a Nanjing hospital showed that 85 percent of young women operated on had their parents' blessing. One anonymous mother was quoted as saying she would support her daughter's decision, "so long as the surgery is safe and affordable."

Since its legalization, plastic surgery has mushroomed into a US$3 billion industry, with around 1 million clinics nationwide employing about 6 million people. Adverts for surgical weight loss and breast enhancement clinics have become commonplace in the elevators and taxis of China's cities. In Shanghai, reports of a surge in nose jobs and facelifts for both young men and women emerged in early February - couples were even giving each other the gift of surgery for Valentine's Day. Thanks in part to the deft promotion of the "man-made beauties" and the influence of Han liu (loosely meaning "trends from Korea" - where it is estimated that at least 50 percent of women have had plastic surgery), there appears to be less stigma attached to getting "done" than in the West.

Vanity aside, some young Chinese say they are undergoing operations for more practical, career-related reasons. Many job ads still list as a requirement "appropriate appearance", a code word for physical attractiveness. Such overt appearance-based discrimination is still legal in China, unlike many other countries, although it could be said that favouritism towards the beautiful is a universal phenomenon.