Health Check

For sheer entertainment - not to mention educational - value, nothing beats the company of a plastic surgeon. They have, after all, a unique insight into the vanities, foibles, and insecurities of humankind.

For sheer entertainment - not to mention educational - value, nothing beats the company of a plastic surgeon. They have, after all, a unique insight into the vanities, foibles, and insecurities of humankind.

I sat next to an American cosmetic surgeon on a flight from Washington last week and over seven hours I was treated to a series of anecdotes on woman's - for it is usually her - quest for beauty.

Did you know, for example, that the most popular implant in Brazil is in the buttocks not the breasts? The beach culture, combined with cultural differences in the ideal body shape, determine which features are emphasised. But what, I wondered later, can they be like to sit on? Can it really be true that so many opt for their own internal cushion?

South Americans are more comfortable with their vanity than either the Americans or the British and wear their surgical enhancements with pride. Business is so good that Sao Paulo, Brazil's second city, has no fewer than 400 plastic surgeons, about the same number as serve the entire UK.

My surgeon, of Hispanic origin, confided that he had first been attracted to his wife, who was sitting across the aisle, by the shape of her rear. He loved his work, judging appearances, juggling ideas of beauty and, with the help of computer manipulated images, working to produce a result that the patient could see before submitting to the scalpel.

In Maryland, where he worked, there was a high demand for liposuction from his overweight clients. But whereas for white women it was their hips and thighs that were the main concern, black women worried about their bellies. So long as they had a trim waist they did not care what was carried below it.

Breasts - usually too small but sometimes too large - were what also brought him a lot of custom. In his early years - he was now 45 and clearly prosperous - he had operated on a lot of strippers who wanted breast enlargement. "They were the most asexual women. They were doing it for business. It was about power and money, not sex.," he said, with evident distaste.

They also wanted it done cheap, which is why he doesn't treat strippers now, since he has become successful and raised his prices. What he sees instead is a different effect of breast enhancement - in an increased risk of divorce.

It is extraordinary, he said, how often six months after a woman has had breast implants she will file for divorce. It seems, for many women, the improvement in their appearance is enough to boost their confidence to go out and start a new life independently of their husbands. Strange how cosmetic surgery, often seen as a mark of female oppression, can also lead to emancipation.

Men make up a much smaller proportion of his clients - though an increasing one. The main market is among salesmen who are in their mid-forties feeling under pressure from younger rivals and struggling to retain their youthful looks. The most popular operation is on the area around the eyes - to lift bags and smooth out crow's feet - those tell-tale signs of ageing.

When he was young and hungry he accepted all comers for treatment, but now that he is successful he can afford to be more circumspect. Plastic surgery is fraught with potential for disappointment and it is important to assess patients carefully in advance.

Yet there is no predicting reactions. He described the case of one woman on whom he had carried out a liposuction with, on his own admission, disastrous results. When she returned for a follow-up consultation he prepared himself for a difficult interview and was ready to suggest revision surgery. Instead, she greeted him with a hug and told him how delighted she was with the treatment. Beauty, at this cosmetic level, is indeed in the eye of the beholder.

There is no accounting for patients' attitudes to their surgeons - perhaps because they have few ways of judging their work other than by how they feel - oh, and by the size of their bill.

Julian Stainton, the exuberant chief executive of private health insurers Western Provident Association, whose study tour to the US I had joined, tells a story about a surgeon in Bristol with a private practice who wanted to retire.

His wife thought this a bad idea. "Don't do that," she told him. "Your patients depend on you. Why don't you raise your prices instead?"

The surgeon took her advice and doubled his prices. Two years later he had doubled the size of his practice.

Mr Stainton explains the phenomenon thus: "You will never hear someone say at a party, 'I got my operation done cheap'. You will hear people say, 'Oh yes, I had my operation but it was very expensive'."

Now there's a thought - that pleasure in medical care is directly related to pain in the wallet.