A surgeon penetrates the bridge between your two nostrils. Tweezers enter the space created by the incision, lifting the skin off your nose as if it is the hood of a car. Now comes the scalpel, cutting bone and transforming cartilage until the nose takes on its desired shape. This disquieting and quease-inducing procedure—rhinoplasty—should be familiar to anyone who has been even remotely attuned to mainstream American culture since the 1980s; this is a nose job, a tangible reminder that people will do crazy things to stay beautiful.

The U.S., with its old-money, mink-donning socialites and fading Hollywood icons whose Walk of Fame stars have been trod on just a few too many times, is reputed to be the world’s plastic surgery leader. Another country, though, has wholeheartedly embraced the surgery of self-improvement.

In 2014, for the first time in history, Brazil overtook the United States in cosmetic procedures. Brazil accounts for 12.9 percent of all the world’s plastic surgeries, just edging out the 12.5 percent of the U.S. What initially seems like a trivial difference takes on a new significance when one considers that the population of the U.S. is over 50 percent greater than that of Brazil. The statistics raise even more questions when one takes into account that U.S. GDP is approximately eight times that of Brazil. And yet, Brazil is outpacing the U.S. in operations per capita, with 74 plastic surgeries performed per 10,000 people compared to 45 in the U.S.

Despite Brazil’s unfortunate reputation for poverty-plagued, crime-ridden slums, its people have demonstrated a remarkable skill for upward mobility, much like the country itself—now the world’s eighth largest economy. This relatively new prosperity has awakened a long dormant consumer society. Over 35 million Brazilians have escaped from poverty in the last 12 years, creating a new lower middle class that is far from prosperous but also far from destitute. It is these people for whom self-confidence and self-love are no longer luxuries, and it is this income bracket that is fueling Brazil’s plastic surgery trend.

However, the economic boom does not fully explain plastic surgery boom. The answer lies in culture, particularly in cities dotting Brazil’s massive coastline. Dr. Paulo Da Luz Moreira, an associate professor in the Spanish and Portuguese department at Yale and an expert on Brazilian issues, describes Brazil as having “a very strong beach culture, an environment where you’re practically naked in front of everyone else since you’re a baby.” Such an environment may increase the pressures to conform to popular perceptions of beauty and youth. This trend is expensive, but it is made more affordable by Brazil’s tradition of retail financing in installments: consumers split payments with retailers to mitigate exposure to abusive interest rates, making cosmetic procedures available to citizens of the middle class who could otherwise not afford them.

The culture and openness surrounding plastic surgery in Brazil is different than almost anywhere else in the world. Plastic surgery in the U.S., on the other hand, is still shrouded in stigma and taboo. Just a few months ago, actress Renee Zellweger’s apparently altered appearance on the red carpet set off a storm of negative publicity and criticism about the procedures she had supposedly undergone.

In contrast, body modification is a status symbol in Brazil, showing both that you care about your appearance and can afford to pay for a new one. Dr. John Persing, current vice president of the American Association of Plastic Surgeons, told The Politic that plastic surgery in Brazil is “a normal routine for people who can afford it, much like changing hair color was fifty years ago.” During his extensive professional touring of Brazil and its cosmetic clinics, he came to the conclusion that American acceptance of plastic surgery is “not at the same level as in Brazil, where cosmetic surgery is not hidden from friends and the general public and is sometimes emphasized.” He recalled going to lunch at a popular restaurant in which the diners sitting at the next table over “had obviously had rhinoplasty the day before” and were making no attempt to hide this fact. Such openness about plastic surgery has made those who would otherwise fear stigmatization for wanting to alter their appearance embrace attempts at self-improvement.

There is a dark side to the plastic surgery boom in Brazil, though. As Persing noted, regulation on plastic surgery is much more relaxed than it is in the U.S. and Europe. This lack of regulation does offer at least one obvious benefit: prices are kept relatively low by virtue of the sheer volume of people offering cosmetic procedures; a facelift in Rio de Janeiro costs about $8,000, versus over $14,000 in California. The downside, though, is that some people with no training whatsoever conduct injections. While injections such as Botox and collagen may seem relatively straightforward, especially in comparison to more complex procedures, a botched session can lead to permanent disfigurement.

The potential downsides were brought to the forefront of national news when Andressa Urach, a runner-up in a national beauty pageant, was left hideously deformed. Chemical filler injections, meant to give more full-looking legs, began to eat away at her flesh. The situation further deteriorated when she went into shock during a corrective procedure. Newspapers published horrifically graphic photos of the now wheelchair-bound Urach with tennis ball size holes in her legs and thighs.

Yet Brazilians continue to flock to plastic surgeons for touch-ups, full-body makeovers, and everything in between. Brazil has an apparent surplus of plastic surgeons, a particularly shocking fact stemming from a country that had to import 10,000 doctors from Cuba to fill its need for doctors in poor areas and the countryside. Foreign plastic surgeons have gotten the message that there is money to be made in Brazil. A short online search of Brazilian clinics yields a surprising number of websites for foreign doctors. Dr. Dennis Hurwitz from Baltimore counts Beverly Hills, Pittsburgh, and São Paolo among the sites of his private clinics.

Yet no single doctor has risen as high as one of Brazil’s very own. Dr. Ivo Pitanguy is something of a Brazilian celebrity. “The Michelangelo of the Scalpel” has achieved fame and fortune as the country’s most eminent and exclusive plastic surgeon. He lives on a private island, far away from the hustle and bustle of his clinic in Rio de Janeiro, and he speaks in impossibly elegant rhetoric about the plastic surgeon’s job as “the search for harmony between body and soul.” The idea that a plastic surgeon could achieve national fame sounds absurd to an outsider, but it is what he does with his fortune that takes Brazil’s plastic addiction into the realm of the surreal. Pitanguy clinics are charity-bent. They do the same type of pro-bono work that American plastic surgeons do: fix babies with cleft lips, burn victims, and those disfigured by accident. But they have one more category of surgery that one would not see in the U.S.: the charity cosmetic surgery. Pitanguy’s clinics offer highly discounted cosmetic operations, such as breast augmentation, rhinoplasty, and collagen injections, to the needy and underfunded.

The idea of offering charity cosmetic surgery may strike one as odd, and yet, an argument could be made that it is just as much an issue of quality of life as any other charity case. Why should the rich monopolize self-love? The U.S. suffers from the highest rates of eating disorders and self-harm in history. Can we reject the possibility that a hatred of our own looks can be just as crippling as a more traditional disorder? What the plastic surgeons of Brazil argue is that they are not just reshaping bodies but saving those who would otherwise spend their lives mired in self-hatred.

One has to wonder if such a pervasive culture of body modification can harm a national psyche. While “a minority” argue that plastic surgery is an act of feminist empowerment, Dr. Marianne LaFrance, professor of Psychology and Women’s, Gender, and Sexuality Studies at Yale, said that “the evidence would still strongly suggest that women are overvalued for their appearance and are often in the position of doing everything and anything they can to change their appearance.” She also said that there is “a remarkable consensus cross-culturally on what’s an attractive face, what’s an attractive body.”

That consensus tends toward a European standard of beauty. In a country that is largely mixed-race because of a history of slave importation from Africa, the leading celebrities and fashion models—Gisele Bündchen comes to mind—tend to be primarily blonde and light skinned. Even Claudia Alende, the winner of the 2014 Miss Bumbum pageant, wears blue contact lenses in public appearances. Dr. Sharrona Pearl, a professor at the University of Pennsylvania and an expert in physiognomy—the study of the face—has studied how women of color often strive for an Anglo look. “Skin lightening is still widely practiced despite the dangers,” she told the Politic. “There is still a lot of surgery in different countries to make noses narrower and to get the epicanthal folds reduced.” While plastic surgery has given more freedom to women (and men) to control their own bodies, such modifications may be converging towards a whiter perception of beauty.

Whatever the reasons and effects, the plastic surgery culture of Brazil shows no signs of subsiding. In fact, it has even become essential in a competitive job market for women to abide by cosmetic norms in order to make themselves more marketable to job interviewers. On one hand, this is a very proactive approach to the issue of aesthetic conformity. By shattering the taboo and inaccessibility surrounding plastic surgery, Brazil may finally be giving its people a way to love their reflections. Maybe one day they won’t feel the need to change the person looking back at them.

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