In the Bonesetter's Waiting Room

by Aarathi Prasad

  Bandra Kurla is also home to the Asian Heart Hospital, a large, multi-speciality health complex built, like most of the surrounding neighbourhood, only a decade or so ago. Offering everything from robotic surgery to neurology, orthopaedic to dental and cosmetic surgery, it is the hospital equivalent of a luxury hotel.

  I was there to meet Dr Satish Arolkar, serving president of the Indian Association of Plastic Surgeons and the man responsible for introducing India to liposuction and, back in the 1980s in the days before silicone implants, breast enhancement by fat graft. In the intervening years, Dr Arolkar would tell me, once Mumbai had overcome its initial qualms regarding the vanity and drastic nature of aesthetic surgery, it had forged ahead and never looked back.

  Data from the International Society of Aesthetic Plastic Surgeons make it hard to disagree: India is certainly at the centre of a worldwide boom in cosmetic surgery. In 2011, out of the 15 million people who resorted to plastic surgery to enhance their looks, 466,231 were Indians. That puts India well within the world top ten by number for a range of procedures, the most popular being breast augmentations and liposuction. In 2011 alone nearly 25,000 women had breast enlargements, a further 13,561 had breast reductions and 9,000 more had their breasts lifted to correct sagging. And it wasn’t just women: around 8,000 men also had their ‘man boobs’ surgically reduced. A total of 41,628 people underwent variations of the liposuction procedure which Dr Arolkar had introduced to India around thirty years earlier, while another 15,000 had tummy tucks.

  As these figures suggest, plastic surgery in India is huge: 2015 estimates put the worth of its overall cosmetic surgery industry as Rs460 crore – around £70 million – which is set to rise to over £17 billion by 2019. As I went up to Dr Arolkar’s office I passed publicity posters featuring world-famous Bollywood stars. Styled with an uncharacteristic seriousness, the actors were there to give a well-loved face to the very advanced – and very expensive – surgical offerings of an industry which is now nearly as important to Mumbai as their own.

  I was immediately struck by how Dr Arolkar’s career had been shaped by a unique combination of clear-sighted ambition, serendipity and an open and creative mind.

  ‘I wanted to do surgery all along, even at university,’ the doctor, a slight and kindly man in his sixties, began after apologising for not offering me tea, something that is apparently not allowed in consulting rooms, even if you happen to be a top surgeon. ‘In the second year of med school I’d do minor things – biopsies, for example,’ he continued. ‘Then I started getting interested in scar formation. At that point I met a friend at university – he was from the school of arts – [who] had been developing prostheses through carving and sculpting in silicon rubber.’

  Dr Arolkar’s admiration for his friend’s creations was palpable, and the excitement with which he spoke seemed to dissolve the intervening decades. ‘He had made a finger that was so realistic,’ he continued, ‘it had hairs and pink nails – it looked just like a living finger.’ For much of his early career, his medical expertise was put to use for charity and he spent a large part of his free time applying his new-found skills to those disfigured by diseases such as leprosy or severely injured in accidents. In some cases Arolkar had almost miraculous success – a man whose arm was caught in a printing machine and crushed up to the elbow, for example, had the damaged limb’s basic function restored and was able to return to work.

  The impact made by Dr Arolkar and his team during their periodic and unpaid stints in deprived agricultural and industrial areas was profound, allowing people to return to their communities or support themselves after injuries which a few years before might have been career ending. And they worked hard, completing up to 500 hours of surgery per visit, usually at night. There was often no electricity, no autoclave for sterilising surgical equipment and little to eat. ‘We only had boiling water for sterilisation,’ he told me, ‘and I brought my own tools. When there was a power cut, we would hold a torch up and continue.’

  But though the work was gruelling, and undertaken in desperate conditions at a time when cosmetic surgery was still a novelty regarded with some suspicion in India, the hundreds of hours Dr Arolkar and his small band of fellow student doctors put in were valuable in more ways than one.

  ‘In the meantime, I was earning a living as a surgeon in Mumbai,’ Arolkar continued. ‘Most of my work was to correct hare lips and cleft palates as well as reconstruction following leprosy. At that time, plastic surgery was considered unusual here in the city – you have to be very vain, people said, to do it. It actually took a long time for aesthetic surgery to get into the limelight because it was seen as something unnecessary. So in 1982 nobody really knew what cosmetic surgery was in India.’

  This was all set to change, however, and Arolkar’s experience would stand him in good stead, as would the ‘phenomenal’ teaching he received from Dr N. H. Antia, then a leader in plastic surgery who had trained under the famous Sir Harold Gillies. Gillies is known as the ‘father of plastic surgery’, a visionary surgeon who both pioneered reconstructive surgery techniques on soldiers wounded in the First and Second World Wars and performed some of the first sex-change operations. As attitudes shifted, Arolkar and his small band of specialist colleagues were in prime position.

  As Dr Arolkar was talking about the scarcity of plastic surgeons in India even as recently as thirty years ago, I couldn’t help thinking how ironic it was that the very first plastic surgeries were performed in ancient India. A form of rhinoplasty is thought to have been invented by an Indian surgeon in around 800 BCE. Though it had already been adopted in a modified form in medieval Italy, the ‘Indian nose’ came to the attention of British medical professionals and public only during the days of the East India Company. Late in 1794 a curious letter was published in the Gentleman’s Gazette, a popular London magazine. Signed only ‘B.L.’, it seems to have been sent from India by an artist, Barak Longmate, who had made an engraving of an Indian cart driver called Cowsajee. Longmate recounts the tale of this former employee of the East India Company who made the error of being captured and imprisoned by Tipu Sultan, the King of Mysore, a region then much coveted by Britain. Already allied with the French East India Company, Tipu Sultan bore a particular grudge against the British, who had broken a treaty to support his father against the neighbouring Maratha kingdom. With British soldiers and their allies, especially Indian ones, Tipu Sultan was famous for showing no mercy and – even though he had been pensioned by the East India Company after the last Anglo-Indian war had ended two years before – Cowsajee, who unfortunately for him also happened to be Marathi, had his right hand amputated and his nose cut off by Tipu’s orders.

  Barak Longmate’s letter to the Gentleman’s Gazette recounts how Cowsajee lived without a nose for about a year. He may well have been saving up from his pension during that time because at the end of the twelve months he travelled to Puna to see a surgeon about having a little cosmetic work done on his face. The British doctors who were able to observe the procedure, in which a living graft of skin was cut from the patient’s own face to reconstruct the missing nose, were apparently appropriately impressed.

  The procedure that Cowsajee underwent – a version of which was still being used by Antia at his Mumbai hospital’s Tata Department of Plastic Surgery in the 1980s – would have been developed certainly before 250 BCE and probably around 1500 BCE, when it begins to be obliquely alluded to in ancient texts. It is detailed in the world’s oldest written manual on surgery, the Sushruta Samhita, which derives from the work of Suśruta, an Ayurvedic physician who may have worked in Varanasi in 1000 or 800 BCE. Suśruta had emphasised surgical training as an integral part of medical education and as the most important part of Ayurveda, an ancient professionalised medical system in India. His Samhita, widely thought to have been written down around 600 BCE, painstakingly documented preoperative and postoperative care, diet and surgical indications and contraindications of various diseases such as bowe
l perforation, hernia, obstetrical injuries, anal fistulae and fractures of the arms and legs. Suśruta developed and applied plastic surgical techniques for reconstructing noses, genitalia and earlobes, among other things, and it is in his work that we first find a description of the ‘Indian nose’.

  The details of the operation were as follows: a pattern corresponding to the size of the nose to be repaired was cut from the leaf of a creeper. The template was then used to cut a similar shape from the cheek. The cheek skin was sutured with a sharp needle and cotton thread over where the nose would have been. Incisions were made where the nostrils would be and the outer skin was turned in. Two tubes (stalks of the castor oil plant) were inserted into the new nostrils to allow normal breathing and prevent flesh from hanging down. The newly attached cheek flesh was then dusted with three plant-derived powders called Pattanga, Yashtimdhukam and Rasanjana (liquorice, red sandal-wood and barberry) that had been pulverised together. Finally, the nose was enveloped in cotton and several times sprinkled over with pure, refined sesame oil. When the flap of skin removed from the cheek had successfully healed over, any excess skin was removed and tidied up with some final trimming and suturing.

  This use of the cheek flap later developed into the similar forehead-flap method that Barak Longmate documented: ‘This operation is very generally successful,’ he wrote. ‘The artificial nose is secure, and looks nearly as well as the natural one; nor is the scar on the forehead very observable after a length of time … This operation is not uncommon in India and has been practised from time immemorial.’

  Unsurprising, then, and perhaps almost inevitable, that thousands of years of experience in aesthetic plastic surgery, a fast-growing cadre of Indian cosmetic surgeons and Bollywood role models willing to embrace the modern Western fashion for self-enhancement should combine to place Mumbaikars at the forefront of India’s cosmetic surgery boom.

  ‘The culture changed totally,’ Dr Arolkar continued as we carried on talking over a delicious lunch in the strictly vegetarian hospital canteen. ‘[Now] people come and say, I want a little tuck here, bigger lips – it’s swung like a pendulum the other way. I have been president of the Indian Association of Plastic Surgeons since 2013, though they’ve now reduced the term to two years because this field has become so popular.’ But, as he went on to say, success has brought its own problems for the industry. ‘Because of this there are also now a lot of quacks coming up who are not trained in surgery at all … so insurance premiums and claims are both rising. Regulation is almost absent. We do have a consumer court and a civil court – and technically anyone can go there and complain, but really we need advisory medical bodies and councils to review this.’

  Worryingly, an estimated fifty-five per cent of rhinoplasties conducted by reputable Indian plastic surgeons are repairs to those that have gone wrong in the first instance, having been carried out in unregulated, often illegally operated small-town clinics by unqualified practitioners. A 2011 Times of India investigation found that patients were often discharged within a few hours of being operated upon. Without regulation, competitive pricing means that, for many patients, the sole determining factor in where they choose to be operated on is cost.

  For patients who do pick the wrong surgeon, the consequences can be severe, even fatal. A famous Tollywood (Telugu) actress, Aarthi Agarwal, who was refused liposuction by her Hyderabad surgeon went ahead with the procedure in America. She died, aged thirty-one, of respiratory problems soon after. Aarthi’s Indian surgeon had turned her down because she had very little fat under the skin – which is what liposuction is supposed to deal with. The procedure is not appropriate either for removing large amounts of body fat or for treating the ‘skinny-fat’ phenomenon: the sort of mid-waist fat that is internal, wrapped around the organs, and common in Indians, stemming from either genetics or the pre-natal environment. Add to that the change in many Indians’ diets to high-calorie foods, an increasingly sedentary lifestyle and the decline of the perception that big is beautiful and it becomes clear that the demand for liposuction will probably escalate further still.

  In the absence of regulation, Dr Arolkar believes the onus has to be on would-be patients to assess their doctor’s credentials before going under the knife. ‘They also need to be aware of complications,’ Dr Arolkar told me. ‘But either way the risks of dissatisfaction are high, because now some people don’t really know what they want. They say they want to become more beautiful, but they don’t know what they want to change! Sometimes I think, actually, you need a brain change, because I’ve seen people who were asking the impossible.’

  I was intrigued that what people are asking for were clearly expensive procedures. In Mumbai, a tummy tuck will set you back more than Rs200,000 – around £2,000. This is ten times cheaper than the United States in absolute terms (though when adjusted for the cost of living the affordability to someone earning an average middle-class Indian salary is probably similar). There’d be a similar price tag on breast augmentation, while a nose job starts at Rs100,000. Why were people willing to spend so much on procedures that, as Dr Arolkar said, would until recently have been seen as entirely unnecessary?

  ‘The thing is, people are becoming more aware of their exterior and showing more of their body, so blemishes get amplified,’ Dr Arolkar told me. ‘I’ve had some very strange requests – like one lady asked me to move a mole to another part of her body. Another time, a girl came to me and asked if I could get rid of the smallpox vaccination scar from her upper arm. Then a boy came to me with slightly floppy ears. He was twenty-three. They really weren’t all that bad so I told him to go away. He wouldn’t, so I asked him for three times as much as it should cost, just to put him off. He turned up the next day with the money. He had sold the motorbike his father had given him.’

  ‘Do you understand why he was so desperate?’ I asked.

  ‘Peer pressure. There was a man from a village in Gujarat who wanted six fingers! Turned out lots of people had that in his village. The thing is, you don’t want to look out of the ordinary.’ Satish told me how some actresses were asking for breast reductions even in their seventies. ‘In the old days, actresses were larger, they had full breasts – in India it was a good thing, it was a sign of fertility.’ Traditional representations of the human form in India do seem to have an extensive history of fêting the rotund rather than the svelte. From the rounded stomachs of Harappan adult male and buxom female figurines, to corpulent personifications of scriptural heroes on the shikara of modern temples, beauty has seldom been the ripped abdominals of the classical Greek ideal.

  In more recent decades, the perception of the ideal body, at least in Mumbai, has publicly undergone a seismic shift. Instead of looking like the boy next door (with a bit of puppy fat), movie heroes became sexy versions of the incredible hulk. Where actresses were once rounded and buxom, they began to follow a trend towards size zero. Bariatric (stomach stapling) surgeries are big business (and openly flaunted by politicians, according to Dr Arolkar). Then in 1991 unfavourable economic conditions forced devaluation of the rupee and an influx of foreign investment followed. In the ensuing decades the Indian economy almost quadrupled in size. Foreign capital flooded into Bollywood and Bollywood in turn became a global export. Western influence increased with the establishment of MTV and the arrival of international glossy fashion magazines such as Vogue. Now, India’s fashionable were watching the world – and the world began looking back. Projected onto gigantic screens wherever its diaspora could be found, the exquisite faces and perfect bodies of the Mumbai film industry’s celebrities were constantly before the public gaze – adoring, or critical. It makes perfect sense that Mumbai would embrace cosmetic surgery the way it has. Nowadays, of course, it’s not just celebrities who are constantly observed: India also has 118 million active social media accounts. Staying current, including knowing what it means to be beautiful, has never been more immediate.

  For those whose jobs require them to stay in the lime
light, the pressures are even more acute. In an industry where appearance is everything, there is a particular vulnerability: adoration might turn to career-ending criticism without warning. The media are, of course, only too ready to ridicule anyone who either has surgery or who does not conform to their own version of perfection. It’s a lose–lose situation. Unsurprisingly, many celebrities who do have procedures go to great lengths to keep them secret. Dr Arolkar had already cautioned me that talking to an Indian celebrity about their cosmetic surgery would be next to impossible, but I knew of two people who, early on, had broken ranks to speak publicly about plastic surgery: the actress Koena Mitra and one of Bollywood’s few female film directors, Farah Khan.

  Despite roles in several Bollywood films, Koena’s fame as an actress was overshadowed by becoming an exemplar of the perils of plastic surgery. ‘She’s sort of insignificant now,’ a magazine editor told me. ‘Her entire career was ruined by bad surgery.’ Though I was unable to secure an interview, she has previously commented extensively on her experience, speaking frankly about the choices she had made and the impact they had had on what could have been a significant career in Bollywood.

  A former model (with a masters degree in psychology), it’s hard to see what could have been improved upon before her surgery in 2011 – after all, that symmetrical face, wide almond eyes and enviable figure had already won her beauty crowns and catwalk gigs. By contrast, in the ‘after’ photos her face seems more stiff, mask-like. But noticeable though the difference is, the true cost of her nose job was measured in more than aesthetics. Koena said that, after the rhinoplasty, her ‘bones started swelling up’ and that a series of corrective operations ensued. She was left in severe pain and housebound, while rumours circulated that her face had been so disfigured that it was difficult for her even to smile.

  The studios shied away and her career ground to a halt. In a 2014 interview she told the Times of India, ‘I sat at home initially. But I could not take it any more and started going out with that face of mine … I didn’t hide anything. But people spoke and wrote the worst … about me.’ She was also quoted in a film magazine talking about the scale of plastic surgery consumerism in Bollywood. ‘I can give you a long list of names with their long list of surgeries,’ she said. ‘My list of surgeries is really tiny compared to many leading stars of the day. I at least had the courage to come out and talk.’ And though her face has recovered, it is no longer one that mainstream Bollywood has since deemed attractive enough to cast.