Lebanon is bleeding, but its plastic surgery industry is not

Lebanon has long been known as the botox capital of the Middle East. Anecdotally, it is thought to have one of the highest rates of plastic surgery in the region - if not the world - though the lack of statistics kept by relevant bodies makes it difficult to verify. 

But since October of 2019, the country has spiralled into an economic crisis that the World Bank has labelled one of the worst since the 1850s. Upwards of 80 percent of the country’s residents live in poverty, with the average salary hovering around 50 dollars, depending on the exchange rate. 

Somehow, plastic surgeons haven’t had to slow down. 

“Honestly, it has not affected [plastic surgeons] that much,” says Dr Ziad Asmar, a plastic surgeon who operates out of his clinic in a suburb of Beirut. 

Some of this can be attributed to a culture of plastic surgery in the country, but the primary reason, according to Asmar and others, is Lebanese expats. 

“The Lebanese diaspora is coming more and more, and since prices have gone down a little, they want to do more and more work.”

There are roughly 15 million Lebanese living abroad, a number that is triple the amount of people who live inside the small Mediterranean nation. Lebanon's history with conflict has scattered them across the world, but a high percentage still have connections with the country, which is highly dependent on remittances and expatriates’ fresh dollars. 

Dr Chadi Murr, a plastic and reconstructive surgeon in Beirut’s Lebanon American University Hospital, says half of his client base is made up of Lebanese expats, which was not the case prior to 2019. 

“The business is less consistent than before [the crisis] but expats have largely filled in the gaps and taken advantage of prices, which have dropped about 25 percent,” he says. 

Asmar expects expat travel to Lebanon during the holiday season will lead to a further spike in injections and surgeries. 

Sarah, a 27-year-old Lebanese expat living in the United Arab Emirates who routinely does lip injections when she comes back to her native Beirut, says she’s happy to be putting her money into Lebanon, but also feels guilty. 

“Obviously, I love the fact that I’m able to get a procedure done more often than I could previously afford. To pay 200 dollars for quality injections is practically unheard of.” 

“But do I feel bad knowing that 200 dollars is more than three times some of my friends’ salary? Of course,” she says. 

The brain drain

When the crisis began, several industries - including the prominent healthcare industry - began crashing. In August, when the country was experiencing a critical fuel shortage for the third straight month, the renowned American University of Beirut Hospital put out a chilling warning: if the hospital does not receive fuel in the next 48 hours, 55 patients will die immediately. 

While the crisis was averted in the immediate via donations from well-to-do civilians, many hospitals, clinics, and pharmacies still struggle to buy necessary resources. Dozens of international pharmaceutical medications have been off the shelves for years, and locally-produced medications, when readily available, are not widely trusted. 

“The main concern for a lot of patients who came to see me was if there will be anaesthesia. Or, they would call me and say ‘doctor, which medications should I bring with me?’” says Dr. Asmar. 

Other plastic surgeons echoed Asmar, and all say they wouldn’t be performing surgeries if there was any lack of necessary resources. 

Dr Murr says it’s doctors that take the hit when they lower their prices. Cheap substitutions are never an option. 

“We can’t change the price for resources, only our fees.”

Coupled with political instability, dangerous conditions - including the Beirut Port blast that killed over 200 people on August 4 2020 - and the continued spiral of the local currency that has lost over 90 percent of its value in the last two years, the crisis has forced thousands of professionals out of the country in a phenomenon known as brain drain. 

An estimated 20 percent of doctors have already left, and visa applications to popular destinations like Canada, West Africa - home to over a quarter million Lebanese - and the Gulf have soared well above average. 

Dr Murr says his reasons to stay are a mix of practicality and national duty. 

“Lebanon has always been unstable. [The crisis] never stopped the business. We maybe saw a minimal drop but overall I’m happy,” said Murr, who also works as a reconstructive surgeon at a military hospital. It is work he says he wouldn't give up as he considers it a service to his country.

Along with Asmar, Murr agrees that plastic surgeons have had an easier time with the crisis compared to other doctors, such as physicians, who must deal with a precarious insurance system that largely pays doctors in Lebanese pounds, and at low exchange rates. 

But, Murr admits, he is not absent from the impact of the mass exodus of medical staff.

“When you lose a good nurse, it’s like you’re losing ten. We’re definitely losing the young people.”

Dr Elie Abdel Hak, who has been operating in the country since Lebanon’s Civil War and served as the President to the Lebanese Society of Plastic Reconstructive and Aesthetic Surgery between 2018 and 2020, agrees that the current situation could have an impact on the future of plastic surgery in the country, as young people are no longer wanting to return to Lebanon to practice, instead seeking a better quality of life and consistent wages. 

There’s also the fact that, according to him, Lebanon’s infamous problems with corruption are not absent from the industry. 

Since the crisis began, there has been a rise in doctors posing as plastic surgeons, he says, and as long as there are no major hiccups in the surgery or injection, nobody will be charged.

What’s more is that the Lebanese Society of Plastic Reconstructive and Aesthetic Surgery is in and of itself limited by corruption, he says. 

“There are some examples, if you’ve heard. I have been aggressive. And I did my work.” 

In 2018, the Society wrote a report condemning the actions of famous Lebanese plastic surgeon Nader Saab, whose patient died while Saab was performing liposuction. 

According to the report, the death was due to negligence. He was charged on three counts, but never served time and still operates in Lebanon. 

Abdel Hak says it’s rare for patients to know about such cases of malpractice because authorities rarely act on the findings of the society, which are sealed from the public. 

Instead, he says, in the absence of authorities who work to weed out bad apples, the industry relies on the hallmark professionalism and expertise of the vast majority of Lebanese plastic surgeons. 

He doesn't believe corruption makes the industry unsafe, but says it does allow for cover-ups. 

“The regulations.. there is a lot. But to execute them.. there is not a lot.”