8.1 Introduction

The practice environment for plastic surgeons nowadays has changed tremendously both internationally and domestically. Internet has substantially modified our way of living and shrunk the world we live in. To plastic surgeons, the social network and various Internet platforms are now essential components of practice advertisement and patient recruitment strategies. These platforms have also provided more opportunities for international consultations and their eventual procedures. Domestically, the population make up of each nation is more diversified than ever. The United States, for example, has seen a tremendous growth of the minority population. From 2000 to 2010, there is a percentage drop of the Caucasian population from 75 to 63% while experiencing a concomitant growth of the Hispanic and Asian population from 12.5 to 16.3% and 3.6 to 4.7%, respectively. ¹ Further it is estimated that by 2050, Hispanic will become the largest minority and comprise of 24% of the nation’s population. ²

As the population structure changes, so is the make up of our cosmetic patients. Cosmetic patients in the USA have predominately been Caucasian in the past; however, in the last decade, there has been a steady growth of cosmetic surgery performed in ethnic minorities. A 10-year retrospective analysis showed from 1998 to 2007, there were actually 1.8% decline in Caucasian cosmetic patients but increases of 7.5%, 4.7%, 14.5%, and 105.5% in Black, Hispanic, Asian, and native American patients, respectively. ³ More recent data from the ASPS in 2015, Asian Americans represent 7% of all cosmetic procedures; Black and Hispanic represent 9% and 11%, respectively (▶Table 8.1). All minority groups combined to 31% of all cosmetic procedures performed in 2015 and continued to have positive growth from 2014. ⁴

One thing that remains constant is the popularity of liposuction procedure. Across ethnic groups, liposuction continues to be one of the top cosmetic procedures performed. ² Since each culture has its own preferences and cosmetic ideals, as a plastic surgeon of the 21st century, it is of paramount importance to understand the different needs of patients from various ethnic backgrounds.

8.2 Ideal Body Shape

To define the ideal body shape for any culture or even a small group of people is an impossible task. “Beauty is in the eye of the beholder”, and how the beholder identifies beauty often comes from his/her own cultural upbringing and fashion trends of the time. Throughout history we see examples of cultural beauty like the foot binding in ancient China, elongated neck with brass coils in the Kayan tribe, and the corset binding of the Victorian era. These now seemingly extreme standards of beauty were once considered norm in the societies then.

With the current globalization, however, standard of beauty and fashion for the first time unifies and influences the world instantly a few mouse clicks away. The less common ideals of beauty mentioned above are not seen and most beauty magazines around the world portrait images of beautiful men or women with more or less variations of a theme.

We as plastic surgeons also have tried to standardize beauty with measured proportions and defined beauty from ideal population norms like the Penn numbers for breast and nipple measurements and Gunter’s nasal measurements. ^{5 , 6} Liposuction, compared to rhinoplasty, has less variation of the ideal goal across cultures.

For liposuction of the arms and legs, the goal is always to restore the youthful, tightened cylindrical shape if the skin elasticity is appropriate. As for the trunk, an hour-glassed curve from the breast to waist then hip is desired across all ethnicities (▶Fig. 8.1). Singh et al further defined 0.7 as the ideal waist to hip circumference ratio across culture. ⁷ Though this ratio can be followed as the general guideline, there are variations of the shape preference in the buttock region; paying attention to these details will reward you with higher patient satisfaction. The list below identifies the general ethnic buttock ideals in the USA (▶Fig. 8.2).

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  African American: Though 0.7 is cited in many studies as the ideal waist to hip ratio, smaller waist to hip ratio (WHR) is often tolerated and desired. A study showed that African American men are more likely to choose a lower WHR as ideal compared to their Caucasian counterpart. ⁸ This means a more exaggerated curve between the waist and hip. Very full lateral buttock and lateral thighs are often desired; liposuction of these areas is to be avoided. Often times they might actually request these areas to be fat grafted. While a gentle posterior inward curve from the buttock to lower back is favored in all ethnic groups, African Americans often prefer an exaggerated lordosis with a shelf formed by the superior buttock. Also for many African Americans, the lateral trochanter area is considered the hip, instead of the common iliac crest area. ⁹

  
  
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  Hispanic: A very full lateral buttocks is also preferred but only slight fullness of the lateral thigh is desired compared to African Americans. ⁹

  
  
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  Caucasian: Either a rounded lateral buttock or a hollow athletic shape is preferred. ⁹ No lateral thigh fullness is desired, so this area along with the medial thighs are often requested to be shaped with liposuction.

  
  
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  Asian: No lateral thigh or lateral buttock fullness is preferred. These areas are often requested to be liposuctioned by Asian patients. Asian pelvis is usually smaller than other ethnic groups so less liposuction volume can achieve the same or greater effects. ¹⁰ Asian patients also tend to use liposuction for shaping rather than for total body fat reduction. The BMI in Asian patients is typically normal already, they often come in for a specific part of their body where fat tends to accumulate, ie. medial or lateral thighs, love handles, and posterior flanks. There are, but less common, full body liposuction requested compared to the other groups.

These descriptions are generalizations of the ethnic patients specifically in the United States. There are of course individual variations within a certain ethnic group. The environmental influence is also great. There are studies that showed African Americans picking up more Caucasian ideals of beauty when they moved into the Caucasian social circle, and vice versa. ¹¹ Differences between nations also apply. While thinness is valued equally high in a study comparing the body perceptions of American students and Chinese students, the students in China value slenderness with plumpness while American students value slenderness with an athletic and firm muscular look. ¹²