Photo courtesy: Knape—Getty Images
By Daniel Roberts
July 31, 2014

The country that launched the “Battle of the Bulge” in World War II is now leading the way in the battle over a different kind of bulge.

German men went under the knife for 2,786 penile enlargement surgeries in 2013, according to the International Society of Aesthetic Plastic Surgery (ISAPS), which today released its 2014 global stats report. That’s a much larger tally than the other nine countries that provided sufficient survey data this year, including the U.S., Mexico, Spain, Italy and Brazil. Other than Iran, the U.S. had the fewest penile enhancement surgeries, at only 61. The report tallies surgeries performed last year.

There are other compelling tidbits to be gleaned from the data. In contrast to its lack of interest in penis enlargements, the U.S. is leading the way in breast augmentation surgeries (more than 313,000 to Brazil’s 226,000; those two nations trounced all others in this category). But don’t be quick to assume that means American women are more eager than non-American women to enhance their bodies. The data are broken down by geographic location but not nationality, which means that it was not necessarily all American citizens undergoing the surgeries performed in America. For the purposes of the annual survey, the ISAPS reached out to some 35,000 plastic surgeons around the world. The countries that responded with the most data were the U.S., Brazil, Mexico, Germany, Spain, Colombia, Italy, Venezuela, Argentina and Iran.

Dr. Eric Halvorson, who does cosmetic and reconstructive surgeries at the Brigham and Womens Hospital in Boston, Mass., had no guess as to why Germany would be leading the penile enhancement charge, but he told Fortune that, of course, standards of aesthetic beauty vary by country, and the surgeries reflect that.

Take women, for example, who had 87% of the total plastic surgeries in the world. “In the U.S., women tend to want to be thin with large breasts, whereas in a country like Brazil, women want to have small breasts and a larger buttocks,” Halvorson explained.

“It’s amazing: take the same woman’s body, and in one country they’d be going to get their breasts reduced and their buttocks augmented, and in the other they’d be getting larger breasts,” he added.

Breast enhancement was, unsurprisingly, the most common type of plastic surgery worldwide in 2013, with 1.77 million performed globally, beating out simple eyelid surgeries, of which there were 1.38 million. But augmentation is only one type of breast surgery, a category that also includes breast lift, breast reduction, and gynecomastia surgery (reduction of abnormally large breasts in men). The U.S. accounted for 15% of breast surgeries in the world, just edging out the 14.9% performed in Brazil. Other operations measured in the ISAPS survey include tummy tucks (Brazil had the most; the U.S. is a close second), vaginal rejuvenation or labiaplasty (Brazil and Germany both had more than the U.S.) and buttock augmentation or gluteoplasty (the U.S. was only fourth here, after Brazil, Mexico and Colombia).

This was in fact the first time ever that Brazil topped the U.S. for most surgical procedures performed. Although America has 15.2% of the world’s plastic surgeons (Brazil is catching up, with 13.6%), Brazil had 12.9% of the world’s aesthetic/cosmetic surgical procedures, compared to 12.5% by the U.S. That’s not to be confused with non-surgical procedures, which have risen more than ever before and which the U.S. leads by a wide margin. This category of shorter, cheaper procedures includes injections of Botox or soft-tissue fillers, skin lasers and skin-tightening devices, fat-melting and fat-freezing devices.

Dr. Renato Saltz, who is vice president of ISAPS (and grew up in Brazil), says non-surgical procedures have been riding a wave ever since 2008 and 2009, when there was a slow-down in surgical procedures due to the economic crisis.

“Patients couldn’t afford the big-ticket operation, but they still did something,” said Saltz. “They did some laser, some Botox, they still wanted to look better despite the financial crunch.”

In 2010, the U.S. numbers for surgical procedures finally started growing again, and non-surgical procedures have continued to rise. In 2013, Americans spent more than $12 billion on cosmetic procedures, according to ASAPS, the American-focused version of ISAPS. That was up 12% from 2012. Some $5 billion of that was on non-surgical work.

“In my practice we’re seeing more and more patients coming in who don’t want to have actual surgery, or don’t want to pay for it or wait for it,” Saltz said. “They come in, they’re on their laptops during the procedure, and then they leave and 25% of the fat in their tummy is gone. These are certified procedures that didn’t exist five or ten years ago, and that change we’re seeing is amazing.”

Ask Dr. Halverson, though, and he’ll tell you that the general lack of knowledge about non-surgical procedures is one of the frustrating things about being in the plastic surgery field of medicine.

“I think reality TV and the media has done a lot to show plastic surgeries and raise consciousness and make it seem okay; people always used to hide it, but now people are much more open about it, it’s much more acceptable to have had surgery,” said Halvorson.

“The downside of [reality shows about plastic surgery] is that they reinforce the public perception that plastic surgery is nothing more than cosmetic surgery,” he added. “If you look at the classic text for our field, there are ten volumes, and only one of those is cosmetic. We do burn surgery, breast reconstruction, cranial and facial trauma, tissue transfers, a whole range. But that’s one of my pet peeves, is that for the rest of my life, when I go to cocktail parties and people ask what I do, I always have to follow it with various qualifying statements.”

It isn’t just television that has had an impact, but also the Web, in the opinion of Dr. Saltz.

“With the Internet, beauty has been sort of globalized,” he noted. “So you have Brazilian patients who want to look like Angelina Jolie. One of the fastest growing things in the U.S. is butt augmentation, and one of the fastest growing in Brazil is breast augmentation. I think a lot of this is totally related to social media and Facebook. And it’s a different patient now, thanks to the Internet; they come in and sometimes they think they know more than you do. They’ve done research and if you don’t do the same new type of butt augmentation as this guy in Rio, well, they’re going to fly to Rio.”

Just as you’d expect, when Halvorson is at one of those social gatherings and says he’s a plastic surgeon, people tend to immediately mention “nose jobs” and “boob jobs.” Maybe now, based on some of the most striking data points in the ISAPS survey, they’ll also ask about penis jobs.

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