Plastic Surgery Hasn't Always Welcomed Black Folks — It's Time for a Shake-Up

When Steven Williams, MD, was a plastic surgery resident in the early 2000s, nose job essentials included a scalpel, a nasal speculum, and a mold depicting the size and shape the post-surgery nose should be. That shape was small with a "ski jump" nose bridge and "a very narrow tip," says Dr. Williams, a board-certified plastic and reconstructive surgeon in Dublin, California, and president-elect of the American Society of Plastic Surgeons (ASPS). "It was considered the classic nose." It was also entirely Eurocentric.

Flash forward: Things are finally, slowly beginning to shift. More Black and brown people than ever are getting cosmetic procedures, according to the American Society of Plastic Surgeons — 1.7 million in 2020, compared with just over 1 million in 2010. (The white patient population went from 9.2 million to 10.3 million during this same period.) At the same time, plastic surgery is evolving, with more focus on individual beauty and preserving ethnic differences instead of, say, giving everyone the same pert nose. 

Meet the experts:

• Steven Williams, MD, is a board-certified plastic and reconstructive surgeon in Dublin, California, and president-elect of the American Society of Plastic Surgeons (ASPS).
• Charles Boyd, MD, is a board-certified facial plastic surgeon in Birmingham, Michigan, and treasurer of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS).
• Kelly Bolden, MD, is a board-certified plastic and reconstructive surgeon in Washington, DC.
• Kristin Denise Rowe, PhD, is assistant professor of American studies at California State University, Fullerton.

In a culture where Black women have been held to dominant Eurocentric beauty standards, this slow but steady shift in plastic surgery ideals indicates that we are moving in a different direction. Not only are more Black patients seeking cosmetic surgery, they are going into providers' offices knowing what they want and, maybe more important, what they don't want. The best of aesthetic medical providers are listening to the concerns of these patients and empowering their individuality.

"Black don't crack" has been a mantra of pride, but it has wrongly informed skin-care and aesthetics decisions.

Black patients — and Black surgeons — have been underrepresented in plastic surgery. Only 11% of patients who get cosmetic surgery are Black, according to 2020 statistics from the ASPS, and some estimates show about 2 to 3% of plastic surgeons are Black. But the fact that more Black patients are seeking out these services may indicate that they are overcoming psychological barriers to care for themselves in this way, says Dr. Williams. 

For decades, the phrase "Black don't crack" has been a mantra of pride for the Black community, but it has wrongly informed important skin-care decisions, like what is adequate sunscreen use. The phrase is also behind some of the reservations Black people have when considering cosmetic procedures, says Charles Boyd, MD, a board-certified facial plastic surgeon in Birmingham, Michigan, and treasurer of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). "I say, 'It is true that black doesn't crack — we don't get as many lines or wrinkles,'" Dr. Boyd explains. "'But it does sag and droop.'" 

The thought of cosmetic enhancement is now becoming more acceptable to Black patients, says Dr. Boyd, whereas in the 1990s and 2000s they might have associated plastic surgery more with botched procedures on Black celebrities. In many Black households, obvious rhinoplasty that entirely altered a star's appearance or face and body implants that defied natural proportions made it taboo to even talk about going under the knife. 

Now Dr. Boyd, with the swipe of his finger on a phone or tablet, can show before-and-after photos of his own patients to skeptics and demonstrate tasteful transformations. "They are really blown away, because they're like, 'Wow, I didn't know that was possible,'" he says. "And they'll say, 'She doesn’t look like she’s had work done' or ‘He doesn't look like he's had work done.’" That's the point, Dr. Boyd adds, because "when you've had good work done, no one can tell."

Black Americans, women specifically, are also becoming more transparent about their experiences with plastic surgery. For example, in recent years, stars of Real Housewives of Atlanta and Real Housewives of Potomac — two of Bravo's franchises in which Black women dominate the cast — have been open about undergoing cosmetic procedures, including RHOA's NeNe Leakes and RHOP's Wendy Osefo and Mia Thornton. Rapper Cardi B made headlines when she addressed plastic surgery rumors on Lizzo's song "Rumors," in 2021, setting the record straight that she had a "fake ass, fake boobs." Cardi B has maintained that candidness by telling fans about her butt implant removal too. 

These pop culture conversations pique patient interest and influence their buy-in, says Kelly Bolden, MD, a board-certified plastic and reconstructive surgeon in Washington, DC. She points to representation on social media as another force that has catapulted change forward. Says Dr. Bolden, "Sometimes [Black women] just coming across my [Instagram] profile, not knowing anything about me, but seeing me, it's, 'Oh, my gosh, here's a Black woman who's doing plastic surgery.' I think, in a way, it gives them permission to say, 'Okay, let me at least go talk to her about it.''"

Still, aesthetic medicine is just starting to fully broaden representation so that people of all colors, ethnicities, and backgrounds feel included. Dr. Boyd has served as a consultant on ads for now mainstream cosmetic procedures, like certain neuromodulator injectables, and commented on the models' proximity to whiteness. "All of the women of color in there, if you were to lighten their skin, they'd look like white women," he recalls. "I mean, in terms of the nose, the features, the jawline, the hair texture, it was all the same." This was over 10 years ago, Dr. Boyd adds, and the companies have since responded with more inclusive representation in their advertising. 

The next shift, Dr. Bolden says, will be ensuring that aesthetic health care providers are aware of and knowledgeable about the aesthetics and beauty standards for non-European ethnicities and races. But as more Black women become open to plastic surgery and cultural momentum steers away from Eurocentric beauty standards, the industry also has to resist implying that there is a single Black standard of beauty. 

Adopting a uniform model for Black beauty standards, says Dr. Boyd, "assumes that every Black woman or Black man has the same nose, the same hair texture, the same jawline, the same mid-face, and that’s certainly not true." A narrow idea of what a pretty girl who's not white looks like — in which colorism and anti-Blackness can still reign supreme — means there is a lack of understanding within the aesthetics industry of the cultural diversity and beauty of each race. Ultimately, this does a disservice to women across all races and ethnicities. 

"We have gotten better at understanding that there is no one single thing that makes someone beautiful."

All of those ski-slope nose jobs started with the training of plastic surgeons. "The teaching was very consistent about what an 'ideal' nose should look like," says Dr. Williams, who completed his plastic surgery residency at Yale University in 2005, when he was the first — and only — Black plastic surgery resident in his program. The standardization of this nose shape was reinforced in the literature cosmetic surgeons read, and then trickled down to patients in the procedures they received. That era, Dr. Williams continues, "really exemplifies the perspective of plastic surgery — and plastic surgeons — and what we were telling patients they should expect and what they should think is beautiful." 

In more recent years, the evolution of cosmetic surgery has included a perspective shift, where patient input has become more prevalent — discussions about the nose or breasts they actually want, instead of the options they should want. Dr. Williams notes, “We have gotten better at understanding that there is no one single thing that makes someone beautiful.”

Historically, surgeons have focused first on how to conduct procedures successfully and safely, says Dr. Williams. Because the field and these kinds of trials have been dominated by primarily white surgeons and studies have been conducted with primarily white participants, the "studies are all skewed toward one standard of beauty," explains Dr. Boyd, who coauthored a study published in the Journal of Drugs in Dermatology looking at how “treatment of facial aging patterns among white women is well-documented, [but] far less information describes the aesthetic needs of the African American patient.”

Patients are now beginning to seek more of a personal sense of beauty, says Dr. Williams, and surgeons can opt for procedures like ethnic rhinoplasty and preservation rhinoplasty to retain the unique qualities of the patient's nose. "Originally, an 'ethnic rhinoplasty' many times meant changing or de-emphasizing some of the features that might be characteristic of an 'ethnic' nose," he explains. "Both of these terms now reflect an honoring of some of those unique features. We’re not going to wipe away all of the characteristics that may be associated with your nose. But good plastic surgeons are going to address specific concerns in order to achieve beauty for that particular patient, without just saying, ‘Well, we know what a good nose looks like and we’re going to give it to you.'"

Whether a patient comes in for filler to reduce fine lines or a full facelift, the goal should not be to become a different person, says Dr. Boyd. Work remains to be done to ensure that plastic surgeons are educated about diverse beauty standards. This is something that will be a priority for Dr. Williams when he assumes his role as ASPS president in October and looks to combat what have been structural barriers to successful health care. "We are working on various things," he says, "such as specific digital learning initiatives that will help make patient care safer and more effective, and having innovative speakers and conversations about inclusion equity and diversity in the space of plastic surgery."

Patients of other races are now eager to get more features that have traditionally been associated with Black women.

Women looking for fuller lips are filling up appointment slots at Dr. Boyd's practices. Lip filler is now the number one most requested treatment among Boyd’s millennial patients, he says. It's a departure from his training as a surgeon in the '90s, when he was taught that the "ideal lip aesthetic" was a one-third (top lip) to two-thirds (bottom lip) proportion. "More women of color, particularly Black women, are more of a one-to-one ratio," he says. 

Surgeons have also seen an increase in patients requesting a lip lift, according to a recent survey by AAFPRS. At least 73% of AAFPRS surgeons performed lip lifts in 2022, up 3% from the previous year. The procedure, which just started trending in the past few years, involves removing some skin under the nose, shortening the skin between the nose and lips, ultimately creating a fuller appearance in the upper lip.

Full lips are one example of features that have traditionally been associated with Black women that patients of other races are now eager to get. Thicker hips and a round, pronounced butt are also in high demand. Gluteal fat grafting, more commonly called the Brazilian butt lift (BBL), is a-two step procedure in which fat is removed from one section of the body and then injected into the hips and buttocks to give the area a different shape. 

But it's a controversial procedure: Though strides have been made toward safer BBLs, as little as five years ago it was the cosmetic procedure with the highest fatality rate. And it’s not unheard of for people to travel abroad for BBLs, to the Dominican Republic, Mexico, and the Philippines, for example, places that do not meet U.S. safety standards and have higher complication rates. Recently, four Black Americans traveled to Mexico for one member of the group to have a BBL, and they were tragically targeted by a cartel; two were kidnapped and two were killed. "Whether or not you like this [traveling for plastic surgery], whether or not you understand this, people do this, and especially, a lot of Black people do it," reported USA Today. 

The letters BBL have stuck for describing any kind of butt or hip augmentation, but "there are a lot of different flavors of BBL," says Dr. Williams. A mini BBL doesn't require as much fat transfer and produces a less dramatic result, while hip augmentation BBL fills out the hips for more of an hourglass shape — a departure from the waifish figures and size-zero supermodels that used to dominate mainstream beauty culture. 

Experts attribute this wave of acceptance for once-shunned ethnic features to celebrity influence and the megaphone of social media. American society has been granted access to watch very famous women touting and accentuating features that counter Eurocentric beauty trends, whether it’s through millions of followers or mass media outlets on the red carpet. "Certain celebrities have been hugely influential in the plastic surgery or aesthetics industry," says Dr. Bolden. "Whether you think it's been overdone or not, they've kind of invited society in to say, 'Fuller hips are okay. Fuller breasts, fuller lips, fuller cheeks are also okay.'"

There is painful and political history here, though, when discussing the now en vogue features that have adorned the faces and bodies of Black women without need for surgery, says Kristin Denise Rowe, PhD, assistant professor of American studies at California State University, Fullerton. Sociohistorically, some of Black women’s defining features have existed in systems of both fetishization and oppression. "We know the curvaceous frame of Black women was something that was literally gawked at, mocked, and hypersexualized within the context of the West," says Dr. Rowe. "If we're talking about blackface in minstrel shows, a lot of us might be familiar with the ways that the lips were exaggerated in color and size." 

More bodies being altered to reflect a Black woman's has prompted conversations of cultural appropriation, says Dr. Boyd, even to the extent that "Black women no longer get credit" for features that are naturally theirs. He refers to Kim Kardashian's figure, modified by plastic surgery, for being viewed as the current body ideal, even though Beyoncé, for instance, gave the world a natural apple bottom years before her solo career began. 

Furthermore, as the slim-thick trend (as in, a cinched waist and flat stomach with a larger butt, hips, and thighs) has gained steam in mainstream culture, it has led some Black women to be dissatisfied in their own skin, feeling pressured to surgically alter their appearance, going so far as to put their own health at risk for results. The constant comparisons generated by social media platforms don't help, says Dr. Rowe. There is privilege in having the money and means to see a world-class surgeon and not having to cross country borders to seek a more affordable option; a socioeconomic advantage is required to afford the time needed to undergo cosmetic surgery and safely recover after the operation. But, Dr. Rowe says, the culture hasn't arrived at those kinds of transparent conversations yet.

Can Black women have faith that this recent celebration of more racially distinctive features will last? Dr. Rowe says she's unsure of what the future holds. The pendulum hasn't swung so far as to eradicate, say, colorism. It remains to be seen whether beauty standards are truly evolving or just fleeting trends that have been legitimized because they've been adopted by white people. 

Read more articles from The Melanin Edit:

• A New Filler for Laugh Lines and More Procedures That Are Safe for Dark Skin 
• The Best Skin-Care Treatments for Melanin-Rich Skin
• Vaseline, Cocoa & Shea Butters, and the Legacy for Black Skin

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