Going under the knife can be risky business

David Kennedy, Contributor, Jakarta
d_kenn@yahoo.com

Take a look around any of Jakarta's big shopping malls on a busy afternoon. Notice anything unusual? Now, take a closer look at the sea of faces as they glide by -- there is a good chance some of those faces have had some form of cosmetic skin surgery.

A staggering array of cosmetic enhancements is now offered by dermatologists and cosmetic surgeons across the city and growing numbers of people -- mostly women -- are availing of them.

From chemical peelings to liposuction, rhinoplasty to blepharoplasty, Botox to chin and breast implants -- not to mention the latest laser treatments, demand has increased steadily over the last decade.

As the growth in the beauty parlors and clinics testifies, the Asian financial crisis of 1998 did little to dampen peoples' resolve to improve their looks, often at any price. If anything, it has boosted the business here as it became much more expensive in Singapore.

Over the last decade the numbers of qualified plastic surgeons in Indonesia has doubled from 25 to about 50; in comparison to 10 or 15 years ago. Many surgeons today spend a far greater proportion of their time on esthetic rather than reconstructive surgery.

"We treat in the region of 3,000 patients per month," said Dr. Edwin Djuanda of the Jakarta Skin Center in South Jakarta. He added that after the financial crisis business continued to increase.

"There are so many requests for Botox," he said, referring to the toxin injected to relax muscles in the forehead and around the eyes to reduce wrinkles and lines, "that everyday is 'Botox day' here; we do about 100 injections per month".

Apart from Botox, the most sought after cosmetic treatments include liposuction to remove fat from the body by suction, chemical peeling of the face and laser treatments to reduce blemishes or acne scars.

Among clients of Chinese descent, eye surgery, known as blepharoplasty, to create a crease in the eyelid is in great demand. Rhinoplasty or nose reshaping is also popular among all clients.

Business in breast enlargements is also booming. Clinics like the Jakarta Skin Center use patients' own fat from liposuction or implants of new bio gels coated in protective capsules that can be safely removed later.

Dr. Djuanda acknowledged that for some people, cosmetic surgery had become an addiction.

After the first operation, patients often wanted to change their appearance entirely as if, he suggested, a hormone had been released into the bloodstream, willing them to do more.

"A lady from Makassar (South Sulawesi) had surgery and liposuction here several days ago. She also had her chin done here and then she went to another doctor to do her eyes," he said.

"Shopping around" for treatments with different specialists is a common practice among wealthier cosmetic surgery clients, according to Dr. Djuanda who said he encouraged patients to wait before rushing into a second operation.

The rush for new looks has led to many disappointments and some tragedies. A vibrant and illicit cosmetic surgery trade has taken root in the country -- exploiting the growing demand and apparent lack of concern among clients regarding the qualifications of the person holding the syringe or scalpel.

The proliferation of beauty parlors, illicit clinics and unscrupulous door-to-door salesmen, performing potentially dangerous surgical procedures without medical supervision or adequate facilities is a major cause for concern, according to leading surgeons.

While it is impossible to know the precise numbers of people using illicit clinics and beauty parlors, a reliable indicator of the extent of the problem comes from the number of patients plastic surgeons are treating for complications.

"I treat about a hundred patients damaged in beauty parlors each year," said Dr. Gentur Sudjatmiko, senior plastic surgeon at Pondok Indah and MMC hospitals in South Jakarta.

Dr. Gentur, also a lecturer in plastic surgery and head of the teaching facility at Cipto Mangunkusumo General Hospital in Central Jakarta, does not hide his shock at the damage inflicted by illicit beauty parlors -- 90 percent of which is down to injections of silicon and other dangerous substances.

"Sometimes people's faces are really frightening. They can even look like monsters," he said, carefully weighing up whether the word was strong enough to describe the gravity of the situation.

From 50 registered plastic surgeons across the country -- 20 of whom practice in Jakarta -- and many of them treating similar casualties from illicit clinics, the scale of the problem begins to be alarming.

"At the moment, I am dealing with many injections of silicon," said Dr. Dewo Affandi at Tria Dipa Hospital in Central Jakarta.

He added the main problems are infections, allergic reactions and inflammations. There may also be bleeding from wounds, tumors and deformities as silicon and other fillers move through the body, obeying the laws of gravity.

"Only today I had two patients, one who had injections in the lips and the other with injections in the nose," said Dr. Dewo who treats about 15 such cases per month in addition to his regular work in reconstructive plastic surgery.

"We had to open the nose and analyze the material to determine the pathology before removing it. How many people are being damaged by these quacks?"

In areas like Mangga Besar in West Jakarta, a thriving industry of back street beauty parlors and clinics cater for mostly Chinese Indonesian clients.

Workers in illicit clinics often follow one or two weeks courses in Taiwan and elsewhere in Asia and they gain clients' trust despite their lack of formal qualifications or access to proper medical facilities.

As in all surgical procedures, complications -- ranging from bleeding to infections and inflammations -- can arise at any moment and without the proper medical supervision a person may be badly injured. The results can be disastrous if silicon is injected into a blood vessel or an artery.

"I have heard of cases where people have had eyelid surgery in people's homes, sometimes just sitting on a chair," said Dr. Djuanda incredulously.

The Indonesian Medical Association does not fully recognize cosmetic surgery but promotes a multi-disciplinary approach, as is the case in other countries, requiring practitioners to be qualified surgeons.

While some experts call for stricter regulations of beauty parlors and unlicensed clinics, others underline the weakness of any new approach based on laws and regulations.

"The police cannot sue an illegal clinic unless the patient makes a complaint. However that would take time and money for the patient so they don't do it," said Dr. Dewo, who has been active in discussions on the creation of an association of Indonesian cosmetic surgeons.

Dermatologist Dr. Abraham Arimuko at Kartika Pavilyun in Gatot Subroto Hospital, Central Jakarta, said promoting more awareness was crucial.

"Sometime patients know about the legal ways of getting treatment but they still go to the beauty parlor because it's cheaper," he said, adding that numbers taking this route may have risen by up to 10 percent or 15 percent in recent years.

Perhaps there is a need for a greater understanding of the underlying causes of the growth in illicit cosmetic surgery.

Lamenting the fact that many Asian women want to look western, Dr. Djuanda highlights the influence of Hollywood. "Now everyone wants lips like (actress) Angelina Jolie," he said. "Sometimes they want their lips like one star, their eyes like another and their nose like another."

Television, film and mass media advertising campaigns often sell a western ideal of beauty -- an image that signifying wealth, success and fulfillment.

Dr. Gentur, who performs more than 600 operations per year -- two thirds of them for esthetic purposes, suggests the problem lies in people looking for short cuts to beauty. "They are looking for the easy way, with no effort," he said.

The fact that treatments in beauty parlors are usually, though not always, cheaper than public hospitals is not the major cause of the problem, according to Dr. Gentur.

At training hospitals like Cipto Mangunkusumo, he said operations are usually affordable, and in certain cases they are free. "The big problem is not the price but people don't know about the treatments and where they can have them."