Plastic surgeons struggle to keep up with the demand for their services in Afghanistan. Lianne Gutcher talks to two doctors and the women and men prepared to gamble their looks to make their lives better.
Afghan plastic surgery: On the face of it
The burqa-clad woman shuffles into the clinic with her two children. As she enters, she flips back the sky-blue fabric to reveal thick white bandages plastered across her face. She is at Hamkar Surgical Clinic in Demazang in western Kabul, two days after her initial operation, to see her new nose for the first time.
Shah Gul is not a rich woman, even by Afghan standards. She is a widow and borrowed the money for the nose reduction from her brother, a vegetable vendor. The operation is, she says, her chance to finally feel beautiful after a lifetime of shame and self-consciousness about her large, misshapen nose.
In the examination room, Dr Daud Nazari, 37, peels off the bandages to examine his work. There is still swelling and bruising but there is no doubt that the nose is far more dainty than in the "before" photograph.
"I am very happy," says Gul, turning her head this way and that to examine her nose in the looking glass from all angles.
Over the past decade since the ousting of the Taliban, plastic surgeons - visiting foreigners and the Afghans learning from them - have performed hundreds of operations to correct cleft lips and club feet, to reduce scarring on women and girls who set themselves alight in protest about the misery of their lives, and even to sew back on the ears of men who had been mutilated by the Taliban as a punishment for cooperating with the government or coalition forces.
Famously, the California-based Grossman Burn Foundation is one of many organisations that donate plastic surgery to female "honour victims" in Afghanistan. The foundation gave a new prosthetic nose to Aisha, the girl featured on a controversial Time magazine cover last year who had her nose and ears cut off - with the approval of a Taliban commander - by her abusive husband as punishment for running away.
Now, however, the emerging middle classes, who have been exposed to trends in Iran and India, have a disposable income and are willing to pay for plastic surgery purely for cosmetic reasons. The first two private plastic surgeons in town, Drs Aminullah Hamkar, 52, and Nazari, are struggling to keep up with the demand for their services. Hamkar learnt plastic surgery in the Soviet Union two decades ago. In 2002, after the fall of the Taliban the year before, he returned to Kabul with to setup a private clinic. He offered to train his colleague, Nazari, who, as the one of the pair who speaks English, was interviewed for this piece.
On weekday afternoons, there is a steady flow of patients. A mother arrives with her teenage daughter to ask if anything could be done about the daughter's uneven breasts. The teenager had had an operation, years ago, to remove a cyst, and the procedure had left her left breast half the size of the right one. She is engaged to be married and she is concerned about her future husband's reaction to her deformity.
After a brief examination, Nazari says yes, he could perform a mammoplasty, but the patient will need to find a way to acquire the implant. He himself would struggle to do so. If they can get the prosthesis into the country, he will be able to do the operation.
Next comes a TV actress who wants a tummy tuck after the birth of her first child.
Then comes a young man, a student, seeking a nose enlargement. He came from a poor family. His parents had scraped together the money to send him to Kabul University to become a teacher. He was planning to use the 6,000 afghanis (Dh441) they had given him for living expenses for the first term on surgery.
Unfortunately, he is about 9,000 afghanis short of the 15,000 afghanis the clinic charges students and poor patients for surgery. (The full rate is 25,000 afghanis.) Nazari tries to convince the boy the procedure is unncessary.
"If you give me the money, how will you live for the next term?" the surgeon asks.
"I'll find a way," the boy say. "Can't you do the operation today and I will get the rest of the money in the next few days?
"I am in so much pain," he says of his disgust for his small, Asiatic nose.
Nazari refuses. The boy, crestfallen, gets up and leaves.
Nose jobs are a frequently sought-after operation at Hamkar's clinic, as are eyelid lifts. Often the patients are Hazara, one of Afghanistan's ethnic minorities, seeking to make their eastern features - flat noses and deep-set eyes - conform more closely to the Afghan ideal of beauty. Hazaras are Shia, like their Iranian neighbours, rather than Sunni, like the Pashtuns and Tajiks who together make up 69 per cent of Afghanistan's population. Hazaras often take their cultural cues from Iran, hence the social acceptability of plastic surgery among that population: Tehran, after all, is often referred to as the "nose job capital of the world".
The chadors - the full body cloaks - that Iranians wear draw attention to the face as the only part of the body on display. So it makes sense to want to make those features more attractive. But what about the Afghans who wear the burqa? It seems surprising that there would be a demand for plastic surgery when their faces are covered up most of the time.
"In Afghanistan, women cover their faces," says Ash Mosahebi, a consultant plastic surgeon at the Royal Free Hospital in London. "But behind the scenes, even if it's only females together, they still want to look better."
At Hamkar Surgical Clinic, procedures are quick and dirty by western standards. In cases of nose augmentations, the implant is acquired by cutting a piece of bone from a rib. Both surgeries - rib and nose - are done under a local, rather than a general, anaesthetic. Recovery time after surgery is one hour.
Using a piece of rib is standard procedure, even in the West, according to Mosahebi, who was born in Iran and who moved to the UK when he was 15.
"For nose augmentations, the easiest way is to use a bone or rib," Mosahebi says. "But it is very rare in the UK to do nose surgery under a local anaesthetic. Sometimes it is done in Europe and the US under a local anaesthetic but people are also very heavily sedated. People [in the West] would not tolerate a local anaesthetic for that kind of procedure. There is a higher tolerance in Afghanistan."
A 23-year-old divorcée, Parwin, comes and sits in Hamkar's waiting room dressed in a surgical cap and gown, ready to go under the knife. She is Hazara and has come in for a nose enlargement. She chats happily in good English about having the surgery.
"In Afghanistan, being beautiful means having big eyes and the right-size nose," she says. "We don't think about lips too much. Eyes and the nose - those are the two main things. We don't think too much about cheekbones, either."
She says she isn't scared.
"I am going to do this anyway, so I had to think positive. I've been waiting so long for this," she says. "I phoned my mother this morning and told her that I had a surprise for her - that I would look very different when I came home this evening," she adds, giggling.
A few days later, Parwin is back at the clinic for her first post-operation check-up. She describes being operated on.
"I could see and hear everything going on," she says. "They put a local anaesthetic in my nose but started before it began to work properly. When the knife went in, I was in terrific pain. I yelled and shouted because it hurt so much. When they cut the rib there was a big noise. But I felt I could trust them [the doctors].
"I am very excited about seeing my new nose. It's been a hard wait. For two days after the operation I was really afraid. My eyes were black. I was really sick. I couldn't walk at all for two or three days."
But already she noticed an improvement: "The operation pulled the skin around my eyes, and my eyes are bigger and more beautiful."
When the bandages come off she is pleased but then worries that her nose is not straight. "It's really good. It's better than before. It was nothing before. Now I have something here. It feels really good. But look at this, it's not too straight. It should be like this."
She delicately pulls the nose into line.
"They just have to make it a bit straight. I am happy but it should be straight."
The cost of a nose job around the world
The price of a nose job - a rhinoplasty - can vary significantly depending on the severity of the reconstruction. The three main factors in the cost are the fees for the surgeon, the anaesthesia and the facility. The average figures below (with the exception of those from Afghanistan, Lebanon, the US and the UAE) are from the Treatment Abroad PriceWatch Survey 2008 in the UK; prices assuredly have risen since then, though no survey appears to have been done in the last three years.
Czech Republic $3,206
South Africa $3,883