Journal of Plastic Surgery and Hand Surgery

ISSN: 2000-656X (Print) 2000-6764 (Online) Journal homepage: http://www.tandfonline.com/loi/iphs20

Global aesthetic surgery statistics: a closer look

Paul I. Heidekrueger, S. Juran, D. Ehrl, T. Aung, N. Tanna & P. Niclas Broer

To cite this article: Paul I. Heidekrueger, S. Juran, D. Ehrl, T. Aung, N. Tanna & P. Niclas Broer
(2016): Global aesthetic surgery statistics: a closer look, Journal of Plastic Surgery and Hand
Surgery, DOI: 10.1080/2000656X.2016.1248842

To link to this article: http://dx.doi.org/10.1080/2000656X.2016.1248842

Published online: 15 Nov 2016.

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Download by: [University of Otago] Date: 16 November 2016, At: 19:07

JOURNAL OF PLASTIC SURGERY AND HAND SURGERY, 2016
http://dx.doi.org/10.1080/2000656X.2016.1248842

ORIGINAL ARTICLE

Global aesthetic surgery statistics: a closer look

Paul I. Heidekruegera, S. Juranb, D. Ehrla, T. Aungc, N. Tannad and P. Niclas Broera
a
Department of Plastic, Reconstructive, Hand, and Burn Surgery, StKM - Klinikum Bogenhausen, Academic Teaching Hospital, Technical
University Munich, Germany; bUnited Nations Population Fund, Technical Division, Population and Development Branch, New York, NY, USA;
c
Center of Plastic, Hand and Reconstructive Surgery, University Medical Center Regensburg, Germany; dDepartment of Plastic Surgery, North
Shore LIJ Hospital, New York City, NY, USA

ABSTRACT ARTICLE HISTORY

Introduction: Obtaining quality global statistics about surgical procedures remains an important yet Received 15 March 2016
challenging task. The International Society of Aesthetic Plastic Surgery (ISAPS) reports the total number Revised 17 September 2016
of surgical and non-surgical procedures performed worldwide on a yearly basis. While providing valu- Accepted 4 October 2016
able insight, ISAPS’ statistics leave two important factors unaccounted for: (1) the underlying base
population, and (2) the number of surgeons performing the procedures. KEYWORDS
Methods: Statistics of the published ISAPS’ ‘International Survey on Aesthetic/Cosmetic Surgery’ were Plastic surgery; aesthetics;
analysed by country, taking into account the underlying national base population according to the offi- cosmetic surgery;
cial United Nations population estimates. Further, the number of surgeons per country was used to cal- international statistics;
culate the number of surgeries performed per surgeon. regional distribution;
Results: In 2014, based on ISAPS statistics, national surgical procedures ranked in the following order: geography; ISAPS statistics
1st USA, 2nd Brazil, 3rd South Korea, 4th Mexico, 5th Japan, 6th Germany, 7th Colombia, and 8th
France. When considering the size of the underlying national populations, the demand for surgical pro-
cedures per 100,000 people changes the overall ranking substantially. It was also found that the rate
of surgical procedures per surgeon shows great variation between the responding countries.
Conclusion: While the US and Brazil are often quoted as the countries with the highest demand for
plastic surgery, according to the presented analysis, other countries surpass these countries in surgical
procedures per capita. While data acquisition and quality should be improved in the future, valuable
insight regarding the demand for surgical procedures can be gained by taking specific demographic
and geographic factors into consideration.

Background
Obtaining quality global statistics about surgical procedures
remains an important yet challenging task. While much
improvement has been achieved over the past years through
different organisations and surgical societies, the utilisation
and analysis of such data often remain minimal. In the
absence of harmonised mechanisms to register surgical pro-
cedures, only rare data exist to assess the exact number of
surgical procedures worldwide.
The American Society for Aesthetic Plastic Surgery (ASAPS)
has collected multi-specialty procedural statistics since 1997.
ASAPS recently stated that the overall number of cosmetic
procedures has increased more than 150% since the tracking
of the statistics first began [1]. Similarly, since the late 1990s,
the International Society of Aesthetic Plastic Surgery (ISAPS)
has tracked international cosmetic surgical and non-surgical
procedures and published the results on an annual basis. Since
ISAPS statistics are the only data source for comparing surgical
procedures internationally, the authors wish to provide a more
thorough analysis based on the most current data.
According to the statistics released in 2015, more than
20 million cosmetic surgical and non-surgical procedures
were performed worldwide in 2014. ISAPS represents a lead-
ing international society for aesthetic plastic surgery, with
more than 2700 board-certified aesthetic plastic surgeon
members in 95 countries.
In the 2015 ISAPS report it is quoted that ‘the United
States held the top spot for total number of surgical proce-
dures performed’ [2, p. 4] (Available at: https://www.isaps.
org/Media/Default/global-statistics/2015%20ISAPS%20Results.
pdf). The data presented in the annual report suggests that
the US and Brazil represent the countries with the highest
demand for aesthetic surgical procedures. Accordingly, in
2015 the ranking shown in Table 1 was published of 9 645
395 surgical procedures performed worldwide in 2014 [2].
The ranking’s order seems intuitive and posits that the high-
est demand for plastic surgical procedures exists in the US.
However, in order to assess the actual demand for proce-
dures based on a country’s population, the number of proce-
dures performed needs to consider the underlying base
population. Further, in order to estimate the demand for
plastic surgical procedures per surgeon, the number of sur-
geons who actually perform the quoted procedures also
needs to be accounted for.

CONTACT Paul I. Heidekrueger, MD paul@heidekrueger.net Resident, Department of Plastic and Reconstructive Surgery, Bogenhausen Teaching Hospital,
Technical University Munich, Englschalkingerstr. 77, 81925 Munich, Germany
ß 2016 Acta Chirurgica Scandinavica Society
2 P. I. HEIDEKRUEGER ET AL.

Table 1. ISAPS ranking of yearly performed total surgical pro- Table 2. Distribution of plastic surgical procedures 2014.
cedures in 2014. Adjusted ISAPS Procedures
Country No of procedures Country ranka rank Procedures Population per 100,000
1. USA 1,483,020 South Korea 1 3 440,583 49,090,000 898
2. Brazil 1,343,293 Brazil 2 2 1,343,293 200,674,130 669
3. South Korea 440,583 Colombia 3 7 252,244 47,073,000 536
4. Mexico 381,207 US 4 1 1,483,020 316,148,990 469
5. Japan 326,398 France 5 8 233,615 62,961,000 371
6. Germany 287,262 Mexico 6 4 381,207 117,410,000 325
7. Colombia 252,244 Germany 7 6 287,262 80,511,300 357
8. France 233,615 Japan 8 5 326,398 127,320,000 256
Worldwide total 9,645,395
a
Adjusted rank represents rank based on the number of annual procedures
The authors believe that currently published ISAPS ranking per 100,000 population. Source: Own calculations based on the ‘International
of countries by surgical procedures and international distribu- Survey on Aesthetic/Cosmetic surgery’ by ISAPS (2015) [2] and the United
tion of caseload changes when taking into consideration the Nations [11].

underlying national population. By focusing on the surgeons

and their performed procedures individually, yet another
ranking will emerge in respect to the demand per surgeon.
The objective of this study is, therefore, to interpret the
ISAPS tabulations and break down international differences
in demand for plastic surgical procedures.
Taking into account the number of surgeons practicing in
these countries might also help young or relocating plastic
surgeons to identify areas where demand for surgical proce-
dures per surgeon is likely going to be the highest. Lastly,
national and international organisations and training pro-
grammes can utilise the data to better assess the potential
need for training new surgeons.
Methods
The analyses presented are based on the 2013 and 2014 sta-
tistics of the ‘International Survey on Aesthetic/Cosmetic
Surgery’, as published by the International Society of
Aesthetic Plastic Surgery (ISAPS). ISAPS performs a survey
on an annual basis since 2010. Survey results are
compiled, tabulated, and interpreted by Industry Insights Inc.
(www.industryinsights.com), an independent research firm
based in Columbus, OH.
Survey participants, i.e. surgeons, are asked to complete a
two-page questionnaire collecting information about the
number of surgical and non-surgical procedures. In 2014,
ISAPS send an invitation to participate in the study to 35
000 plastic surgeons. Included were surgeons officially
enlisted in their respective societies. 1391 surgeons replying
resulted in a response rate of 4%.
Country-specific data are only shown for those countries
that provided a sufficient survey response for the figures to be
considered valid. No adjustments other than standard data
editing procedures were applied to country-specific results.
Standard statistical tools (including weighting and extrapola-
tion) were used. The results are published in total and relative
numbers, disaggregated by countries worldwide [2].
The combined ISAPS data allow for international analysis
of plastic surgery statistics. However, comparing absolute
numbers makes actual comparison of demand between
countries difficult. By calculating the rates of plastic surgery
procedures per 100,000 inhabitants in the respective country,
the actual prevalence of plastic surgery can be visualised.
The authors constructed single year datasets of surgical
procedures by country and related these to the underlying
national base population. Subsequently, rates of surgical pro-
cedures performed per 100,000 population were calculated.
Additionally, the number of procedures was related to the
total number of board-certified plastic surgeons practicing in
the respective country, according to ISAPS. Utilising this data,
the authors constructed a new ranking.
Results
Procedures per 100,000 inhabitants
Table 2 illustrates how the total procedures change when
calculated as rate per 100,000 people living in a country.
Broken down by national population, the adjusted ranking is
led by South Korea (former ISAPS rank 3), with 898 proce-
dures per 100,000 inhabitants. Brazil (ISAPS rank 2) ranks
second, with 669 per 100,000. Rank 3 is held by Colombia
(ISAPS rank 7), with 536 procedures, followed by the US on
rank 4 (ISAPS rank 1), with 469 procedures per 100,000
inhabitants. France (ISAPS rank 8), Germany (ISAPS rank 6),
and Mexico (ISAPS rank 4) remain in the midfield (ranks 5
and 6), with 371 and 357 procedures per 100,000, respect-
ively. Mexico drops in position to rank 7 (ISAPS rank 4), with
325 procedures per 100,000, followed by Japan, with 256
procedures per 100,000 inhabitants.
More important than the change in ranking and order,
however, appears to be the fact that the shares are more
evenly distributed when using procedural rates instead of
absolutes. These differences are less extreme and more com-
parable when using the authors’ interpretation, with the
weighted breakdown showing a much more balanced
demand for surgeries than when merely considering absolute
numbers.
Surgeries per surgeon
In a subsequent step, to more accurately depict the actual
workload per surgeon, the ratio of plastic surgeons to the
total number of surgical procedures performed was calcu-
lated (Table 3). Based on ISAPS information, with 6300 plastic
and reconstructive surgeons, the US has the largest absolute
number of surgeons. However, surgeon density per popula-
tion is highest in South Korea, with 4.2 surgeons per 100,000
inhabitants, followed by Brazil (2.7/100,000), Colombia (2/
 JOURNAL OF PLASTIC SURGERY AND HAND SURGERY 3

Table 3. Distribution of procedures per plastic surgeon.

Estimated number of Plastic surgeons per Number of procedures
Country Adjusted ranka ISAPS rank Population plastic surgeons 100,000 capita per plastic surgeon
Colombia 1 7 47,073,000 950 2.0 266
Germany 2 6 80,511,300 1,101 1.4 261
Mexico 3 4 117,410,000 1,550 1.3 246
France 4 8 62,961,000 950 1.5 246
Brazil 5 2 200,674,130 5,473 2.7 245
USA 6 1 316,148,990 6,300 2.0 235
South Korea 7 3 49,090,000 2,054 4.2 215
Japan 8 5 127,320,000 2,221 1.7 147
International total 40,328
a
Adjusted rank is the rank based on the number of annual procedures performed per Plastic Surgeon. Source: Own calculations based on the ‘International
Survey on Aesthetic/Cosmetic surgery’ by ISAPS (2015) [2] and the United Nations [11].

Table 4. Surgical procedures in 2013 and 2014.

ISAPS Adjusted Procedures ISAPS Procedures Procedures Percentage
2013 2013 Procedures Procedures per 100,000 2014 Adjusted Procedures (%) per 100,000 change 2013
Country Population rank ranka 2013 (%) 2013b in 2013 rank 2014 rank 2014 2014 in 2014 to 2014
Brazil 200,674,130 1 2 1,491,721 13 743 2 2 1,343,293 14 669 10
Colombia 47,073,000 5 3 291,954 3 620 7 3 252,244 3 536 14
Germany 80,511,300 4 6 343,479 3 426 6 7 287,262 3 357 16
Mexico 117,410,000 3 7 486 499 4 414 4 6 381,207 4 325 22
US 316,148,990 2 4 1,452,356 13 459 1 4 1,483,020 15 469 2
Worldwide total 11,599,336 1 9,645,395 100
a
Adjusted rank is the rank based on the number of annual procedures per 100,000 population.
b
The overall total number of procedures includes countries that are not listed here as they do not appear in both data collection exercises of 2014 and 2015.
Source: Own calculations based on the ‘International Survey on Aesthetic/Cosmetic surgery’ by ISAPS (2014 and 2015) [2] and United Nations [11].

100,000), the US (2/100,000), Japan (1.7/100,000), France
(1.5/100,000), and Germany (1.4/100,000).
Considering the adjusted procedural distribution, what
becomes more apparent is the substantial difference in
respect to the actual workload per surgeon. Surgeon density
varies greatly between the countries and, hence, considerably
impacts the actual number of surgeries a surgeon performs.
The rate of number of procedures to plastic surgeons also
varies greatly between the countries. For instance, on aver-
age, a plastic surgeon in Colombia performs 120 more sur-
geries on a yearly basis than a surgeon in Japan and,
consequently, with the adjusted ranking, the US and Brazil
drop from the ISAPS rank 1 and 2 to ranks 6 and 5, with an
average of 235 and 245 annual surgeries.
Germany, with a relatively low number of plastic surgeons
per capita (1.4 surgeons), is the country with the second
busiest surgeons, with an average of 260.91 procedures per
surgeon per year. On the other hand, South Korea, the coun-
try with the highest number of plastic surgeons per capita
(5.14 surgeons), appears to be the country where surgeons
are the second least busy, with an average of 214.50 proce-
dures per surgeon per year, even though they perform over-
all the most procedures per 100,000 inhabitants (adjusted
rank 1).
Comparison between 2013 and 2014 ISAPS data
Due to irregularities in data collection, only five countries
qualify for trend analysis over the past 2 years of 2013 and
2014, namely, Brazil, Colombia, Germany, Mexico, and the US.
When comparing ISAPS statistics from 2013 and 2014, the
results of the respective countries show similar tendencies
with respect to ranking. This might be an indication regard-
ing the validity of the collected data (Table 4).
However, all countries except the US display a negative
growth in their annual procedures. Annual surgical proce-
dures decreased by 22% in Mexico, 16% in Germany, 14% in
Colombia, and 10% in Brazil. In turn, recorded surgical proce-
dures in the US increased by 2%. At least for the US, this
trend seems to be confirmed by the statistics from the
American Society of Plastic Surgeons (ASPS) from those
2 years.
Discussion
In most countries of the world no official data is gathered by
national societies regarding surgical and non-surgical proce-
dures. Hence, despite its challenges and low level of repre-
sentation, ISAPS remains the most comprehensive data
source available on worldwide plastic surgical procedures.
However, utilisation of ISAPS data remains limited [3].
The authors made an effort in maximising available ISAPS
statistics for in-depth analysis. Further, the authors combined
ISAPS data with population data of the responding countries
to calculate changes in international distribution and gener-
ate national rankings of surgical procedures.
Based on the authors’ ranking adjusted by potential
demand in countries of performance, one would be less
inclined to define hotspots of aesthetic surgery. However,
certain prevalence for aesthetic plastic surgery persists
among the different countries over the world. Since demand
is influenced by individual preferences, demographic charac-
teristic, reactions to economic changes, as well as geographic
location, there seem to be countries where demand is trad-
itionally high [4].
There further exists strong regional variance in respect to
request for aesthetic surgery. Individual preferences are influ-
enced by where patients live and what they experience:
4 P. I. HEIDEKRUEGER ET AL.
what procedures are performed does not only depend on
the individual’s cultural and ethnic background, but also on
geographic factors, which influence peoples’ aesthetic per-
ception [5].
As recent studies have shown, the impact of ethnic char-
acteristics on aesthetic preferences as well as the ethnic dis-
tribution within a certain region further factor into the
surgical decision-making [5,6].
The differences that exist between the countries regarding
the adjusted numbers of procedures per surgeon appear sub-
stantial. The assumption that, following the saying
‘Competition is good for business’, a high presence of plastic
surgeons positively influences demand, thus stimulating
more plastic surgeries to be performed in these regions,
does apparently not hold true. This fact may provide insight
into geographic opportunities for surgeons who want to set-
tle. Of note regarding the data, considering disproportionate
scarcity of surgical access in low-income settings, many of
the board-certified plastic surgeons will also provide general
plastic- and reconstructive-surgical care [7]. This may skew
the interpretation of the data regarding potential work-load.
There exist additional limitations regarding the quality of
data and consequently also the validity of the interpretation
and the drawn conclusions. Currently ISAPS data are still
based on extrapolations. For instance, the comparison of the
ASPS statistics from 2014, with a total of 1 677 478 per-
formed cosmetic procedures in the US, with the total of 1
483 020 procedures (ISAPS data) yields a considerable dis-
crepancy of almost 200 000 procedures [8]. Compared to the
data provided by ISAPS, which needs to provide worldwide
numbers, the data provided by ASPS can rely on more pre-
cise methods of data acquisition, since they collect their data
through the first online national database for plastic surgery
procedures, Tracking Operations and Outcomes for Plastic
SurgeonsSM (TOPSSM). This data is combined with the annual
ASPS survey, which is sent to ABMS board-certified physi-
cians. All responses are also aggregated and extrapolated to
the entire population of more than 23 000 physicians most
likely to perform cosmetic and reconstructive plastic surgery
procedures in the US. The above-mentioned discrepancy
demonstrates the difficulties when analysing extrapolated
data stemming from various sources. Also, the effect of non-
core specialists performing aesthetic surgery procedures and
medical tourism might factor in when evaluating the
countries’ specific demand for plastic surgery. The main limi-
tation regarding the data quality, however, seems to be the
low response rate of the survey of only 4%. At least, when
comparing the ISAPS data from 2013 and 2014, the results of
the respective countries show similar tendencies, which
might indicate a certain validity of the collected data.
Further, although tabulations published provide insight
into the number and type of procedures broken down by
sex, age, and country, they do not allow for cross-tabulation
or even triangulation of surgical or demographic variables.
Despite this fact, in the absence of large-scale international
data, this study tried to make the available data more com-
parable, despite the potential lack of statistical power.
The fact that the interpretation of the presented data
is not without limitations, given its overall quality, needs
to be acknowledged. In the same context, the importance to
obtain high quality international data remains undoubted
and the efforts of the respective societies in doing so should
be acknowledged. In a next step, it would be worthwhile
investigating if similar regional differences exist in the non-
mentioned countries. As pointed out, the regional break-
down of surgical procedures hides statistical differences
between countries. An attempt should, hence, be made to
publish procedure statistics based on a smaller area, i.e. the
state level or even per province, which would also improve
data quality.
To conduct more rigorous research, in order to be able to
follow cohorts over time and to cross-tabulate patient char-
acteristics, disaggregated data including single year of age of
patients would be beneficial. Procedural statistics should fur-
ther provide more detailed information regarding sex, age,
and ethnicity [4].
Ideally, a common online tool could be used to accom-
plish these goals. In the US, such an online tool already exists
in the form of TOPS (Tracking Outcomes and Operations for
Plastic Surgeons), launched in 2002. TOPS provides an elec-
tronic database to enter case information online or via phys-
ician practice management software and is intended to offer
plastic surgeons a way to submit ‘clinical and demographic
information into multiple, confidential databases, minimise
redundant data entry and provide clinical/practice informa-
tion to plastic surgeons and their specialty’ [9, p. 2].
Access to or establishment of similar secure and confiden-
tial international databases of plastic surgery procedures and
outcomes, with information in an anonymised format, would
enrich the evidence about current clinical trends and allow
for more thorough analysis as well as generation of future
projections regarding the expected demand for aesthetic
plastic surgery worldwide.
The present study confirmed the authors’ assumptions
that international demand for cosmetic surgical procedures
varies from country to country given the influence of a
patients’ geographic background characteristics, and, while
demand for aesthetic surgical procedures reflects individual
preferences, demographic characteristics and reactions to
economic changes, it also reflects the importance of space
[10].
Conclusion
The US and Brazil are often quoted to be the countries
with the highest demand for plastic surgery. However,
according to the presented analysis, and taking into
account the underlying base populations, other countries
lead the ranking. Additionally, evaluating the total number
of procedures performed per surgeon, yet another ranking
becomes evident. Valuable insight regarding the demand
for surgical procedures can be gained by taking specific
demographic factors into consideration. Surgeon density per
regional population varies largely between the regions, pro-
viding evidence of which geographic regions to target
when scaling up surgical performance. In this context, the

assumption that more surgeons feed the demand for sur-
gery does not hold.
Given the still limited access to clinical and demographic
data in the area of plastic surgery, interpretation of the cur-
rently available data needs to be performed with caution,
and the authors advocate to strengthen the availability and
quality of open data sources, for example through inter-
national access to an online program similar to TOPS in the
US, in order to analyse anonymised case information and
strengthen the evidence base with specific, reliable practice
information.
In summary, while demand for aesthetic surgery reflects
individual preferences, demographic characteristics and reac-
tions to economic changes, the importance of space and
population need to be considered as they impact demand
significantly.
Disclosure statement
The authors report no conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
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