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PUBLISHED : Sunday, 22 May, 2011, 12:00am
UPDATED : Sunday, 22 May, 2011, 12:00am


For someone about to undergo a major operation, 23-year-old Parwin looks remarkably relaxed. Dressed in a yellow surgical gown with her hair tucked under a green cap, she sits in the waiting room of Afghanistan's first private cosmetic-surgery clinic, chatting happily about her decision to have a nose job.

'In Afghanistan, being beautiful means having big eyes and the right-size nose. My nose, it is nothing,' she says. 'I have been waiting so long for this.'

Cosmetic surgery is in its infancy in Afghanistan but is catching on thanks to its popularity in neighbouring Pakistan and Iran (by 2005, Tehran had become known as the 'nose job capital of the world'). The emergence of a middle class with disposable income is also driving the trend and the social stigma is diminishing because many Afghan celebrities - politicians, actors and sports stars - are known to have had work done. Two of Afghanistan's most famous cricketers, Taj Malik, the first coach of the national team, and fast-bowler Hamid Hassan, had hair implants after fans offered to cover the cost.

Aminullah Hamkar anticipated the trend. During the decade-long Soviet occupation of the country that began in 1979, Afghans were encouraged to undertake professional exchanges in the Soviet Union. Hamkar was invited to Tajikistan to learn cosmetic surgery and ended up staying for 18 years. In 2002, he invited a colleague, Daud Nazari, to join him in running a private clinic in Kabul. The decision is paying off. The two are struggling to meet the soaring demand for procedures.

On any given afternoon there is a steady stream of patients at the surgery, in the Demazang area of Kabul, which was on the frontline during the civil war. Many of the surrounding buildings still bear the scars from rockets and bullets, but most of the bandages seen in these parts today are covering the noses of burqa-clad women who have flipped back their veils to reveal their post-operation faces.

By far the most sought-after procedure at the Hamkar Surgical Clinic is that which reduces the scars from leishmaniasis (a parasitic disease spread by sand-flies) and burn wounds. Due to a lack of electricity, many Afghan families use gas and oil, and accidents are common.

Increasingly, however, patients are asking for nose jobs, tummy tucks and eyelid lifts.

Shah Gul has returned to the surgery for her first post-operative check-up. She is not a rich woman, even by Afghan standards, and had to borrow the money for her operation from her brother, a vegetable vendor. She has, she says, suffered a lifetime of shame and embarrassment because of her 'large, misshapen' nose.

Daud peels off the bandages and, although her nose is a little swollen, it looks neater than in the 'before' photograph. 'I am very happy,' she says, admiring her new profile in a hand mirror.

Afghanistan's diverse population encompasses many facial features. Tajiks, Uzbeks and Pashtuns - many of whom have broad, humped noses - come to the surgery seeking nose reductions. But the Hazara ethnic group, who are thought to be descended from the Mongols (indeed, some claim, from Genghis Khan himself) and who have Asiatic features, come seeking to transform flat, wide noses, and eyelid surgery to produce wide, round eyes - features that may not be seen by many anyway.

'In Afghanistan, women cover their faces,' says Ash Mosahebi, a consultant plastic surgeon at the Royal Free Hospital in London, Britain, who is of Iranian extraction. 'But behind the scenes, even if it is only females together, they still want to look better.'

Cosmetic surgery Afghan-style is not for the faint-hearted but Parwin, a pretty Hazara, says she is not scared. 'I am going to do this anyway, so I have to think positive,' she says. 'I phoned my mother this morning and told her I had a surprise for her, that I would look very different when I came home this evening.'

A piece of bone will be shaved off Parwin's rib and inserted into her nose. Both procedures will be done under local anaesthetic and, after an hour's recovery, she will be on her way home.

'Most patients prefer not to stay overnight and don't have a general anaesthetic,' Daud says. While it is common the world over for a piece of the patient's rib to be used as the prosthetic, such surgery would usually be performed under a general anaesthetic.

'It is very rare in the UK to do this procedure under local anaesthetic,' Mosahebi says. 'People would not tolerate it for that kind of procedure. There is a higher level of tolerance in Afghanistan.'

The price also differs dramatically. Mosahebi says there are three elements to be considered in the price of surgery: the care facilities, the surgeon and the anaesthetic.

The Ying Clinic, which specialises in cosmetic surgery in Hong Kong, charges from HK$38,000 for rhinoplasty using implants and from HK$52,000 for surgery using the patient's auricular cartilage. Parwin will pay about HK$2,250.

A FEW DAYS AFTER her operation, Parwin is back at the clinic to have her bandages removed and for Daud to check how she is healing. He is pleased with his work and Parwin professes herself delighted with her new nose, though she is worried it is slightly crooked. This is not uncommon in rhinoplasty procedures and Daud will perform another small operation to make her nose straight. She is also pleased how the surgery has altered the shape of her eyes, making them slightly larger.

Parwin explains how the operation went: 'I could see and hear everything going on. They put 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 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.'

It is not just women who visit Hamkar and Daud.

A first-year student at Kabul University comes in, like Parwin, to have his nose made larger. He is planning to use the US$120 his parents have given him to cover his living expenses on surgery. Unfortunately, he is about US$180 short. Daud tries to persuade him that the procedure is unnecessary but the young man pleads, assuring the doctor that if he performs the surgery today he will find a way to pay the rest within the next few days.

'I am in so much pain,' he says, referring to the embarrassment and self-consciousness he feels about his nose. Daud refuses and the student gets up and leaves.

The constraints of performing cosmetic surgery in Kabul are manifold. It is often difficult for surgeons to get the equipment they need. While it is easy enough to place orders for sutures and prosthetics in Pakistan and China, it is another matter negotiating the logistics of getting them delivered to Kabul.

A mother comes into the surgery with her 18-year-old daughter, who is soon to be married. When the girl was younger she had a cyst on her chest removed and the operation left one breast smaller than the other. Her husband-to-be does not know about this and mother and daughter want to know if something can be done before the wedding night.

After an examination, Daud concludes that an implant would correct the imbalance. However, he won't be able to get the prosthetic, but if the family can find the silicon he will be more than happy to do the operation. The two leave crestfallen.

Another drawback here is a lack of professional development. Afghan's problematic passports and the surgeons' lack of cash mean that trips abroad to conferences and training courses are limited. Nonetheless, last spring Daud went to China to hone his skills.

'The most common operations I saw were on noses, eyelids and breasts,' he says. 'These are very common in China. Most Chinese people have flat noses so they want more Western noses. And because Chinese girls and women have small breasts, they want augmentations.'

While at the Southern Medical University in Guangzhou, Daud also learnt about hair implants, a procedure he is eager to perform in Kabul.

'Hair transplants take a lot of time - at least one day,' he says. 'So we can only have one patient from the morning to late afternoon. You put thousands of hairs in one by one.

'At the moment we take just small cases: eyebrows and partial loss of hair. Maybe in the future we can do one hair implant a week, but not more. We have so many patients with different problems. But also we need more microscopes and nurses, because it takes a very long time.'

Across the city, there are a couple of other clinics specialising in hair loss. Patients at the Hal Moy Raftagi ('solutions for hair problems') clinics express varying degrees of satisfaction with the results.

Jamil Barakzai, a 28-year-old engineer at Kabul International Airport, opted for hair implants after fretting that his baldness made him look old and was hampering his marriage prospects. He paid US$300 for the procedure.

'For single people, it's very important to have hair if they want to get married; most girls don't want to get married to bald men in our society,' he laments.

At first, Barakzai says, his new hair looked perfect.

'My friends told me they could see a positive change in my face but they couldn't put their finger on the reason. My family told me: 'See how important hair is? You look 10 years younger. Try to keep it up. You look really smart and handsome'.'

Over time, though, Barakzai has realised there are drawbacks to his new look, including an itchy scalp during the night and the need for regular maintenance.

'I have to wash my hair before I go to sleep [and after I wake up], and I have to comb it for more than 20 minutes. I have to return to the same doctor every month because the hair loses its quality. I have to spend money keeping it up.'

Barakzai is also concerned about the medical staff taking care of him.

'They don't have any certificates from medical universities. They just worked as assistants in Iran and Pakistan and they are abusing the lack of awareness of Afghans to make money. They are not familiar with the equipment they use and they are not expert.'

Mustafa Sidiqi, 30, is a driver for an international non-governmental organisation. He spent US$400 on hair implants because he was tired of people making fun of him.

'It was done perfectly. I am really happy,' he says. 'I have to be careful and see my doctor regularly and spend money on upkeep but that's OK. Nobody can make fun of me now.'

Sidiqi is so delighted, he is considering having other types of procedures done: 'There are some spots and dryness on my face which need plastic surgery to resolve. Fortunately, that is available in Kabul now. I will have to save more money and it will cost more than hair implants.'

Given that many of those who come for cosmetic procedures want to conform to Western ideals of beauty, how likely is it that clinics such as Hamkar's will become the targets of Islamic fundamentalists?

'I am not worried about being a target,' Daud says. 'I don't think it's against the Koran. There is nowhere in the Holy Koran or the Hadith that says to be against it.'

Moazzam Nazeer Tarar, a professor in the Department of Plastic Surgery at Jinnah Hospital in Lahore, Pakistan, and the acting head of the Pakistan Association of Plastic Surgeons, agrees that there is no particular conflict between plastic surgery and religion. 'But a lot of people with strong religious inclinations won't have it done,' he says.

Another constraint that limits Hamkar and Daud is the mornings they feel obliged to put in at public hospitals in Kabul to help the less fortunate. 'Our people, they are poor, they need us,' Daud says.

After he returned to Afghanistan, the Guangzhou hospital invited Daud back for further training. They offered to pay all his expenses if he could pay for the flight.

'The flight was very expensive, so I couldn't go for more training. But maybe in the future,' he says.