SCIENTIFIC CONTRIBUTION Borrowed beauty? Understanding identity in Asian facial cosmetic surgery Yves Saint James Aquino1,2,3,4 * Norbert Steinkamp5 © Springer Science+Business Media Dordrecht 2016 Abstract This review aims to identify (1) sources of knowledge and (2) important themes of the ethical debate related to surgical alteration of facial features in East Asians. This article integrates narrative and systematic review methods. In March 2014, we searched databases including PubMed, Philosopher's Index, Web of Science, Sociological Abstracts, and Communication Abstracts using key terms "cosmetic surgery," "ethnic*," "ethics," "Asia*," and "Western*." The study included all types of papers written in English that discuss the debate on rhinoplasty and blepharoplasty in East Asians. No limit was put on date of publication. Combining both narrative and systematic review methods, a total of 31 articles were critically appraised on their contribution to ethical reflection founded on the debates regarding the surgical alteration of Asian features. Sources of knowledge were drawn from four main disciplines, including the humanities, medicine or surgery, communications, and economics. Focusing on cosmetic surgery perceived as a westernising practice, the key debate themes included authenticity of identity, interpersonal relationships and socio-economic utility in the context of Asian culture. The study shows how cosmetic surgery of ethnic features plays an important role in understanding female identity in the Asian context. Based on the debate themes authenticity of identity, interpersonal relationships, and socio-economic utility, this article argues that identity should be understood as less individualistic and more as relational and transformational in the Asian context. In addition, this article also proposes to consider cosmetic surgery of Asian features as an interplay of cultural imperialism and cultural nationalism, which can both be a source of social pressure to modify one's appearance. Keywords Asia * Cosmetic surgery * Ethnicity * Identity * Medical ethics Introduction In East Asian countries, cosmetic surgery has become popular both as a medical field and as an industry. According to a worldwide survey by the International Society of Aesthetic Plastic Surgeons (ISAPS 2011), China, Japan and South Korea (hereafter Korea) ranked third, fourth and seventh, respectively, in most numbers of cosmetic surgical procedures. Blepharoplasty (eyelid surgery) and rhinoplasty (nose job) are two of the most common facial cosmetic surgeries requested by Asian patients (Macer 2012; Wong 2009). Kung (2010) cites reports regarding the rise of cosmetic surgery in Asia reaching a point where getting blepharoplasty or rhinoplasty has become as easy as getting dental braces. Some authors (Lindridge and Wang 2008; Munzer 2011) attribute this trend to a growing social pressure for Asian women to align with "Western" physical characteristics. Most studies on cosmetic surgery offered to people of Asian ethnicity have involved Asians living in Western & Yves Saint James Aquino ysjames@gmail.com 1 Erasmus Mundus Master of Bioethics, KU Leuven, Leuven, Belgium 2 Radboud University Nijmegen, Nijmegen, The Netherlands 3 University of Padua, Padua, Italy 4 175 Lawson Street, Redfern, NSW 2016, Australia 5 Department of IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands 123 Med Health Care and Philos DOI 10.1007/s11019-016-9699-0 countries like the US (Bernardino and Rubin 2003; Dobke et al. 2006; Kaw 1993). Accordingly, present literature relies on westernisation as a framework. Westernisation refers to adoption of Western culture, lifestyle, or ideology, among other things, by a non-Western society or social group. In this paper we understand "cosmetic westernisation" as the modification of Asian features to appear closer if not similar to Caucasian or White features. The concept of westernisation has been criticised, not only for assuming the acceptance of a relatively harmonious and standardised norm of Western features, but also for mainly focusing on appearance and body image research (Bissell and Chung 2009), and practices of cosmetic surgery (Holliday and Elfving-Hwang 2012). The integration and meaning of cosmetic surgery interventions in the lives of Asians who live in their own countries, e.g. Koreans in Korea, remains to be studied. We decided to explore debates related to two of the most popular facial surgery interventions, namely rhinoplasty and blepharoplasty, to contribute to such study. Unlike other popular plastic surgeries (for example, breast augmentation/reduction), facial modifications like these have long been effectively marketed by cosmetic surgeons as procedures to assumingly benefit women and men with ethnic Asian features (Heyes 2009). Based on the sources of knowledge and key debate themes, we argue that the westernisation critique is too individualistic, and the concept of identity in the context of Asian cosmetic surgery is better understood as fluid, relational and transformational. Methodology It appears that the sources of knowledge and debates of cosmetic surgery in Asians cannot be narrowed down to quantifiable and objective aspects alone. Experts have pointed to systematic reviews missing the narrative dimension of developments in a particular issue (Collins and Fauser 2005). On the other hand, narrative reviews have been criticised for being too subjective (Nind 2006). Therefore, this study attempts to integrate narrative and systematic reviews (Duke and Bennett 2010), thereby combining the strengths of both types of reviews. Objectives The two-fold objective of this review is to identify key sources of knowledge of the debate, and to identify important themes in published articles regarding the ethical issues resulting from surgical alteration of ethnic eyes and nose in East Asian patients (Chinese, Korean and Japanese) in order to provide an in-depth discussion. Search strategy The following key terms were combined: cosmetic surgery, ethnic*, ethics,Asia*, andWestern*.The terms Japan*,China* andKorea*were also used separately to replace the termAsia*. Search limitations included papers that were published in English, and no limit was made on date of publication. Search engines and databases used were PubMed, Philosopher's Index, Web of Science, Sociological Abstracts, and Communication Abstracts. Additional search strategies of backward and forward citations were done using Google Scholar for additional articles. Inclusion and exclusion criteria A total of 108 articles were identified as potentially relevant, with the number being narrowed down to 54 after removal of duplications. The study included all types of papers (articles, essays and research reports) based on the following criteria: articles published in peer-reviewed journals; articles contributing to the debate on cosmetic surgery in Asians, with focus on Korea, China and/or Japan; and articles written in English. Articles (n=8) that were not published in peer-reviewed journals that discussed non-Asian populations, as well as those that were written in another language were excluded. A total of 46 articles were critically evaluated and 15 articles were further excluded based on relevance and depth of discussion, bringing the total down to 31 articles (see Fig. 1). Critical appraisal of the included papers The remaining 31 articles were critically appraised based on their contribution to ethical reflection founded on the debates regarding the ethical implications of surgical alteration of ethnic features in East Asians. The quality of each paper was assessed and classified into four categories: overview, review, reflective debate and expert guidance (Duke and Bennett 2010). The categories were defined based on the literary criteria for debate, including persuasiveness, logic and authority of sources of knowledge (see Table 1). Results Based on the two objectives, the results section (1) provides findings as to the sources of knowledge of the debate and (2) summarises the key debate themes of the published literature on the ethics of cosmetic surgery in Asians. Y. S. J. Aquino, N. Steinkamp 123 Existing literature in Asian cosmetic surgery primarily focuses on women as consumers for two reasons. Firstly, although several authors do mention that there is an increasing percentage of Asian men who seek similar cosmetic procedures, this focus reflects the disproportionately high prevalence of women who undergo cosmetic surgery (Holliday and Elfving-Hwang). Secondly, the discussion is also heavily framed as a gendered issue, with beauty and physical appearance having a stronger cultural significance for women in male-dominant Asian societies like Korea, China and Japan (Kim 2003). Identification of the sources of knowledge of the debate The first part of the review involves evaluation of the source and authority of the knowledge used in the debate. A substantial number of articles are categorised as either "Review" (n = 8) or "Reflective" (n = 12), reflecting a potentially rich discursive exploration of the ethical debate on the implications of cosmetic surgery amongst Asians (see Table 1). The debate was drawn from four main disciplines, i.e. humanities (sociology, anthropology and Fig. 1 Process of literature search and review Borrowed beauty? Understanding identity in Asian facial cosmetic surgery 123 philosophy), medicine or surgery, communications and economics (see Fig. 2; Table 2). Most of the articles under medicine or surgery are published in journals under the subspecialty of plastic or cosmetic surgery (Biller and Kim 2009; Choi et al. 2013; Dobke et al. 2006; Jablonski 2011; Lam 2002; Shirakabe et al. 1985; Sturm-O'Brien et al. 2010). Articles published in plastic or aesthetic surgery journals mainly focus on evaluating facial aesthetic preferences with ethnicity as a variable (Biller and Kim 2009; Choi et al. 2013; Dobke et al. 2006), historical development of blepharoplasty in Japan (Lam 2002; Shirakabe et al. 1985), and ethnic trends in facial plastic surgery (SturmO'Brien et al. 2010). In the articles published in humanities, communications and economics journals, authors often refer to feminist ideology as a reference point (Holliday and Elfving-Hwang 2012; Hopkins 2008; Ja 2004; Karupiah 2012; Kaw 1993; Kim 2003; Luo 2012; Munzer 2011; Murray Price 2011; Wang 2011; Xu and Feiner 2008; Yang 2011). Several authors (Ja 2004; Karupiah 2012; Luo 2012; Yang 2011) Table 1 Classification of papers reviewed (Adapted from Duke and Bennett 2010) Description of the paper and value to literature review Number of papers References Overview Literary nature of the paper: outlines the key themes underpinning debate around cosmetic surgery in East Asians Value of paper: introduces the key messages of the debates, raises questions or awareness Source of knowledge: paper draws on professional sources of knowledge and understanding 9 Biller and Kim (2009), Choi et al (2013), Hopkins (2008), Isa (2003), Jayaratne et al (2012), Lam (2002), Murray and Price (2011), Shirakabe et al (1985) and Wang (2011) Review Literary nature of the paper: summarises debate underpinning cosmetic surgery in East Asians Value of paper: sensitises reader to key features of the debates (what arguments construct the debate and how they are countered) Source of knowledge: underpinning ethical and/or methodology and/or research practice theory, although this is not addressed in depth or research study 8 Bernardino and Rubin (2003), Davies and Han (2011), Jablonski (2011), Johnson et al. (2014), Macer (2012), Motaparthi (2010), Wong (2009) and Xu and Feiner (2008) Reflective Literary nature of the paper: discursive exploration of the ethics cosmetic surgery in East Asians Value of the paper: provides understanding about the ethics embedded within cosmetic surgical practice, through careful and logical development of the issues raised Source of knowledge: combines different sources of knowledge (empirical, craft knowledge, methodology, personal, contextual and philosophical knowledge) 12 Bissell and Chung (2009), Holliday and Elfving-Hwang (2012), Ja (2004), Karupiah (2012), Kaw (1993), Kim (2003), Lindridge and Wang (2008), Luo (2012, 2013); Munzer (2011), Ouellette (2009) and Yang (2011) Expert advice Literary nature of the paper: recounts outcomes of events that have discussed ethics of cosmetic surgery in East Asians; for example, workshop, work groups and conference proceedings Value of the paper: provides guidance and expert opinion with respect to ethical reflection in cosmetic surgery in East Asians Source of knowledge: expert opinion with respect to ethical reflection of cosmetic surgery in East Asians 2 Sturm-O'Brien et al (2010) and Dobke et al. (2006) Fig. 2 Sources of knowledge Y. S. J. Aquino, N. Steinkamp 123 elaborate on patriarchal society imposing upon institutions, as well as economic and social forces that directly or indirectly result in women's appearance concerns (see Table 3 for the summary of ideologies as sources of knowledge). Luo (2012) analyses not just the relationship between women and patriarchal society, but specifically refers to the relationship between the "oppressed" female consumer and the "oppressive" male surgeon. The author describes plastic surgery as a male-dominant field, with male surgeons wielding the power to cut and modify imperfections of women who are typically portrayed as silent. In economics, most authors discuss the relationship of globalisation and capitalism with changes in gendered Table 2 Four main disciplines as source of debate Discipline Main topics Humanities Feminist frameworks on how patriarchal family and labour influences a woman's preoccupation with her appearance (Holliday and Elfving-Hwang 2012; Karupiah 2012; Kim 2003; Munzer 2011; Wang 2011; Yang 2011) Psychological frameworks such as cultivation theory and psychoanalytic theory that may explain how an individual is influenced by his environment (Bissell and Chung 2009; Isa 2003; Macer 2012) Ethical theories on beneficence (Macer 2012) and care of self (Munzer 2011) Medicine and surgery Evaluation of facial aesthetics preferences with ethnicity as variable (Biller and Kim 2009; Choi et al. 2013; Dobke et al. 2006) Historical development of blepharoplasty in Japan (Lam 2002; Shirakabe et al. 1985) Ethnic trends in facial plastic surgery (Sturm-O'Brien et al. 2010) Communications Media and digital communications influence on the practice and acceptability of cosmetic surgery (Bissell and Chung 2009; Davies and Han 2011; Hopkins 2008) Foreign advertising and media influence effect on revaluing women's role and femininity (Hopkins 2008) Economics Influence of globalisation and capitalism on the changes in gendered evaluation of women's role in Asia (Hopkins 2008; Lindridge & Wang; 2008; Murray and Price 2011; Xu and Feiner 2008) Table 3 Main ideological theories as sources of knowledge General socio-cultural influences Holliday and Elfving-Hwang (2012) Discourses in national identity and traditional Korean beliefs, going beyond gender, motivate the practice of cosmetic surgery Karupiah (2012) Body modification procedures are influenced by cultural and societal values Kaw (1993) Cosmetic surgery in Asian-Americans could be seen as a manifestation of cultural imperialism on ethnic minorities Sturm-O'Brien et al. (2010) Cosmetic surgery trend in Asians is affected by cultural perceptions, social status, and a positive perception of cosmetic surgery Feminist ideologies Ja (2004) Patriarchal ideology in Korea defines women's appearances and influences their desires Luo (2012, 2013); Xu and Feiner (2008); Yang (2011) Meinü jingji or beauty economy and how China's accession to World Trade Organization link economy, culture and gender to adapt to the goals of neoliberal economics Lindridge and Wang (2008) Modernisation in China redefines how plastic surgery is a response to the changing roles of Chinese women in society and in family Kim (2003) Neo-Confucian concept of body affects the acceptability of plastic surgery in women Psychological theories Bissell and Chung (2009) Cultivation theory explains how media influences perception in Korean society, specifically the standards of beauty and acceptability of cosmetic surgery Davies and Han (2011) Media and digital technology promote the normalisation of cosmetic surgery in Korea Isa (2003) Lacanian psychoanalytic concept of "the Other" helps in looking at beauty as a language or a system of discourse Ethical models Munzer (2011) Michel Foucault's ethics of care of the self within a context of power relations deals with both the personal and social Macer (2012) Various ethical approaches including utilitarianism and consequentialism, teleology and majoritarianism may help in evaluating the acceptability of enhancement in Asia Borrowed beauty? Understanding identity in Asian facial cosmetic surgery 123 evaluation of women's role in Asian societies (Hopkins 2008; Kim 2003; Wang 2011; Xu and Feiner 2008). China's entry to the World Trade Organization (WTO) in 2001, for example, was often referred to as a major milestone that marked the shift of the Chinese consumer culture. The shift allowed the influx of foreign advertising and media (Hopkins 2008), which led to the development of meinü jingji or "beauty economy" in China (Wang 2011; Xu and Feiner 2008). Economic development and industrialisation were also important factors that led to the capitalist and consumer behaviour of Korean women (Kim 2003). For Japan, Isa (2003) argues that the supposed westernisation of Japanese cosmetic and fashion industry led to the commercialisation of beauty. Isa adds that after the Meiji Restoration of 1868 Japan had considerable cultural exchange with Europe and the US, and it was further promoted with the country's democratisation during the Taisho period (1912–1926). Some articles (Bissell and Chung 2009; Isa 2003; Macer 2012) explicitly refer to psychological frameworks in explaining the motivation to alter one's appearance. Bissell and Chung (2009) discuss the "cultivation theory" in psychology, which explains how exposure to media can influence one's perception, specifically in evaluating attractiveness. Isa (2003) refers to Lacan's psychoanalytic theory of "the Other" to argue that it is a more useful theoretical framework to view beauty as a language or a system of expression. It is suggested that beauty should be seen as a complex living and changing language that could determine a person's role in society. Only three authors specifically refer to ethical theories as sources of discussion. First, Macer (2012) discusses the importance of the principle of beneficence in evaluating the consequences of enhancement in Asia. The author explains various ethical considerations in assessing enhancement procedures, including pursuit of the final good, majoritarianism and utilitarianism, among others. Second, Munzer (2011) discusses an "ethical self" that deals with the body, referring to Michel Foucault's ethics of care of the self. He explains that this care when considered within a context of power relations deals with both the personal and social. However, Munzer criticises the Foucauldian theme as being abstract and without the "normative bite" of moral principles. Third, Motaparthi (2010) refers to the "ethical, cultural, and racial issues surrounding double-eyelid procedures" but does not elaborate on any theoretical framework. Some other authors (Holliday and ElfvingHwang 2012; Karupiah 2012; Kim 2003; Macer 2012) make reference to Eastern ethics, specifically Confucianism, but for the most part refer to it as a cultural ideology that influences women's motivations to have cosmetic surgery. Summary of key debate themes The articles included for this review focus on three main themes: first, how authenticity and identity are portrayed in cosmetic surgery; second, how cosmetic surgery reflects identity in the context of relationships; and third, how cosmetic surgery influences identity through socio-economic empowerment. Authenticity In surgical alteration of ethnic features, the debate looks at whether such procedures result in clients aligning their appearance to the western ideal, or whether these procedures are to be considered a means of improving the self within the culture of origin. Studies have shown significant differences in the facial characteristics of Caucasian with Asian populations (Biller and Kim 2009). The eyes and nose are two of the more common ethnic facial features in Asians that have been subject to modification in cosmetic surgery (see Fig. 3 for a stylised photographic comparison of Asian and Caucasian female face). Asian eyes are distinct due to the absence of or simplified palpebral crease and thicker fat pad on the upper lid (Bernardino and Rubin 2003; Wong 2009), among other key variations. Creating an upper lid crease to create a double eyelid is one of the main features of "Asian blepharoplasty" (Bernardino and Rubin 2003). The Asian nose has been described as having a wide, low bridge and less prominent nasal tip projection, making it appear flatter Fig. 3 Comparison of an Asian (left) and Caucasian female face. Noted differences in eyes: East Asian eyes have smaller or absent upper lid crease (a), with inner epicanthal fold (b) and overall almond shape, while European eyes have larger crease (a), with no inner fold (b) and more oval in shape. Noted differences in the nose: the East Asian nose has wider shape, with flatter bridge (c) and less rounded tip (d) compared to the European nose (image courtesy of www. asianplasticsurgeryguide.com) Y. S. J. Aquino, N. Steinkamp 123 than a Caucasian nose (Choi et al. 2013; Wong 2009). Therefore, augmentation rhinoplasty may involve enhancing the tip and/or alteration of the nose bridge using implants (Wong 2009). Authors who defend the notion of westernisation discuss how medicalisation of ethnic features has resulted in Asian women internalising a Western standard of beauty. This standard may have been based on the so-called golden proportion used in cosmetic surgery based on the GrecoRoman ideals (Jayaratne et al. 2012). With the use of Western-oriented golden proportion, surgeries of Asian features are interpreted as "corrective" and that the features are to be qualified as "abnormal" (Bernardino and Rubin 2003), to use a medically unforgiving yet highly evaluative term. According to Kaw (1993), such corrective surgeries promote beauty standards that influence people to "mutilate" their bodies, just to conform to mainstream appearance in Western communities. Ja (2004) argues that the corrective surgeries have branded the Asian body as inferior and flawed. Even in their countries of origin, the author argues that Asians have similarly adopted the inferior branding and have internalised the Western ideal (Bissell and Chung 2009; Johnson et al. 2014). Arguments against the westernisation hypothesis, which has been considered to be (too) reductive (Davies and Han 2011), can be understood firstly from the perspective of cosmetic surgeons and the cosmetic industry. Cosmetic industry in Korea tends to market the golden proportion as being removed of ethnic significance, and therefore universally applicable. Davies and Han add that universal features are advertised as "consumer" ideals of beauty and symbols of success more than an imposition of one ethnicity to another. In respecting ethnicity, Lam (2002) posits that most plastic surgeons do not necessarily aim for westernisation as exemplified by the pioneering efforts of the Japanese surgeon Mikamo. Rather, the double eyelid surgery Mikamo developed in 1896 aimed to eliminate the look of a traditional Japanese woman, considered impassive and non-energetic, and to reflect the newly emancipated feminine beauty (Dobke et al. 2006). Ouellette (2009) and Wong (2009) argue that feminine beauty with large eyes and double eyelids does not automatically imply westernisation as 50 % of Asians are born with double eyelids. In fact, one study found that some Chinese hospitals present double eyelids as "Oriental beauty" that showcases the "delicate Oriental facial contour", reflecting a resistance against the Western feminine look (Luo 2012). Arguments against the westernisation hypothesis can also be understood from the perspective of women as consumers. Based on in-depth interviews with AsianAmericans, Dobke et al. (2006) claim that Japanese women in the US try to avoid artificial alterations to the point of obvious noticeability. Obvious traces of alterations are often defined as "unnatural" western appearance and are also avoided by Koreans. This may be partly explained by their strong sense of nationalism (Holliday and ElfvingHwang 2012). Instead of aiming for an unnatural western appearance, Luo (2013) contends that women in China aim for a harmonious integration of the so-called wai zai mei or external beauty and ne zai mei or internal beauty. The integration of internal and external beauty also explains how identity in Asian countries like Korea (Holliday and Elfving-Hwang 2012; Kim 2003) is neither rigid nor constant, with the self being considered as fluid, socially embedded and in a state of flux. In China, the fluid self also manifests in how a modern society changes and re-interprets traditional cultural identities and values through body modification (Lindridge and Wang 2008). Hence, instead of copying Western appearance, cosmetic surgery in Asia may rather be interpreted as a means of self-improvement (Holliday and Elfving-Hwang 2012; Kim 2003; Lindridge and Wang 2008; Luo 2013). According to this interpretation, aesthetic enhancement of Asian features is believed to be feasible within Oriental standards of beauty. Consequently, this understanding considers identity as fluid. It depicts the body as an ongoing project that can be modified for the purpose of construction of self rather than for the compensation of perceived cultural inferiority (Luo 2013). Relationships Different types of interpersonal relationships, or institutions, aid in the creation of the female beauty ideal (Bissell and Chung 2009). These relationships may be in the form of family, friendships or romantic partnerships. Based on Neo-Confucianism, the value of the female body in Korea is judged in reference to the roles women play within relationships. Kim (2003) and Karupiah (2012) explain that under the ideology, the female body is controlled to ensure her ability to have children and take care of her family. Although initially seen as unacceptable and disrespectful to one's ancestors (Kim 2003), body modification in Asian communities is becoming more accepted within the context of interpersonal relations. Romantic relationship, for one, has been identified as strong motivation of Asians who seek cosmetic surgery in the US, with women wanting to appear less exotic to Caucasian men (Munzer 2011). Romantic goals are also apparent in one type of gendered construction of cosmetic surgery in Korea called kyorhon son-ghyong or "marriage cosmetic surgery" (Holliday and Elfving-Hwang 2012), which identifies the "right face" that determines a woman's chance of getting married. Apart from romantic relationships, parent-child relationships in Asian communities are also influential in a Borrowed beauty? Understanding identity in Asian facial cosmetic surgery 123 woman's decision to have cosmetic surgery. Scholars have noted that the female self in Korea, for example, is still relational, with her identity embedded within the context of a family (Kim 2003). Similarly, Chinese women are often defined by their role-related relationships, of being a sister, a daughter, a wife or a mother (Lindridge and Wang 2008). Therefore, decisions involving plastic surgery can be associated with the desire for establishing or continuing familial relations. This is apparent in the trend of Korean parents' willingness to fund their children's cosmetic surgeries as graduation gifts (Karupiah 2012), which also transforms surgery into a family-bonding activity. In this sense, considering the decision-making process in the context of interpersonal relations emphasises the interdependent and communal features of identity in Asian communities. Seeking plastic surgery would be seen less as an individual decision but more of a relational or rolerelated endeavour (Lindridge and Wang 2008). Socio-economic utility Most of the articles included in the study discuss the socioeconomic value of cosmetic surgery as a strong motivation for women in Asia. On the individual level, cosmetic surgery is seen as a way to improve standing in the academic, social and economic spheres. In the academic sphere, there are reports of Korean teachers and parents who express their faith in good looks as means to improve a student's performance (Davies and Han 2011). There are also reports of high school students who believe appearance would be more important than abilities and skills in future employment (Holliday and Elfving-Hwang 2012). Employment cosmetic surgery or chig'opsonghyong, for example, exists as the second type of gendered construction of plastic surgery in Korea. It describes the "right face" as youthful with vitality and upper-class looks. Having the right face is perceived to improve one's economic opportunities (Hopkins 2008), which is associated with improved social standing. Cosmetic surgery supposedly improves social standing especially in patriarchal societies where women are discriminated against based on appearance. In a way, improving one's appearance for Koreans and Japanese signifies a woman's elite status as part of the larger Global community (Kim 2003), while for Chinese it can reflect transformation of the communist female ideal into the neoliberal image of a progressive Western consumer (Xu and Feiner 2008). On a national level, the transformation of women as consumers has made the cosmetic industry extremely successful. According to a local study in Korea, cosmetic surgery industry contributes approximately US$0.5 billion in the domestic market (Bissell and Chung 2009). Beyond the domestic market, the popularity of the Korean plastic surgery industry abroad motivated the Korean government to become actively involved in the exportation of the practice (Davies and Han 2011). In fact, during the global financial crisis in 2007, the government temporarily allowed its citizens to claim tax credit for the cost of cosmetic procedures just to protect the industry. Similarly, China's entry to WTO gave great importance to meinü jingji or beauty economy, where the female beauty is utilised to showcase economic power. The Chinese government is also heavily invested in the promotion of meinü jingji as a source of "employment, growth and glory for China" (Xu and Feiner 2008). Three papers (Hopkins 2008; Ja 2004; Kaw 1993) question the supposed socioeconomic utility of cosmetic surgery. Kaw (1993) explains that in multi-cultural societies like the US, surgery as a mode of empowerment does not change the cultural and institutional structures that are the real cause of women's distress. The author emphasises that such procedures further entrench the undesirability of stereotypical Asian features. This leads to women focusing on beauty instead of character and intelligence as the symbol of socio-economic success. Socio-economic success even remains uncertain, since the popularisation of surgery does not guarantee that the access to improvements in physical beauty is open to everyone (Ja 2004). In fact, Hopkins (2008) argues that most women could not afford plastic surgery. As what is advertised, cosmetic surgery encourages the belief in the openness and equal benefits of the procedures, but the reality is that the industry does not permit equal access to beauty. Ja adds that with unequal access the end result is that women become more and more subordinated to plastic surgery. As with the issue of authenticity and relationships, the debate on the issue of socio-economic benefits shows how cosmetic surgery in Asians goes beyond having an ideal face. The surgical procedure becomes more symbolic of how Asian women are transforming themselves to become more modern and socio-economically empowered (Kim 2003; Xu and Feiner 2008). However, the socio-economic empowerment should be evaluated against the social contexts of inequality and patriarchy that may result in further harm against women. Discussion In published debates on cosmetic surgery in the Asian countries chosen for this paper, a tendency could be identified to constrain ideas of (primarily female) identity by founding them on individualistic interpretations of autonomy. As a critical comment to this tendency, we propose that female identity in its current form in this Y. S. J. Aquino, N. Steinkamp 123 context should rather be understood as relational. This is supported by relational aspects of the roles of women in Asian countries. Based on the sources of knowledge included in this review, philosophy and bioethics have limited direct contribution to the debate on Asian cosmetic surgery (see Fig. 2; Table 2). The substantial portion of literature comes from other disciplines including anthropology and sociology and includes both empirical and theoretical studies. We believe this imbalance offers both incentives and opportunities to enrich bioethical debate on the ethical implications of cosmetic modifications of racial features. From individualistic to relational identity Based on the reviewed literature, we propose to understand identity in this context as relational instead of individualistic for two reasons. First, we explain how Asian women's identity is deeply embedded in social relationships; second, we describe how Asian women's identity is both fluid and transformational, reflecting an ever-changing social context. A highly individualistic conception of identity is founded on our traditional understanding of autonomy, which remains to be a contentious concept in philosophy and bioethics. Autonomy can be defined as the ability to act according to one's own agency (Eyal 2012), or it can refer to self-rule that is free from external interference or internal limitations (Varelius 2006). However, for gendered issues like cosmetic surgery, feminist scholars argue that traditional definitions of autonomy are insufficient (Mackenzie 2010; Sherwin 1992). Espousing relational theories in ethics, the authors argue autonomy should be understood as a capacity that develops in a social context. For Asian women, social context is heavily influenced by interpersonal relationships in a patriarchal society. Scholars point out that the female body, and subsequently her identity, is defined by the ability to build relationships and care for the family (Kim 2003; Karupiah 2012). Similarly, the decision of women to undergo cosmetic modifications of ethnic features is often motivated by potential romantic relationships. In other cases, parents themselves drive young women to undergo cosmetic surgery, with parents believing that a particular type of beauty would accord their children improved success in life. With the paradigm of relationships, identity becomes relational and the consumption of cosmetic surgery becomes less as an individual decision but more of a role-related process. Interpersonal relationship as a social context implies a degree of fluidity in identity. Mackenzie (2010) argues that social relations influence individual choice, which, in turn, has the potential to shape identity. In addition, Karpin (2014) argues that fluid conception of the self allows for a complex and embodied account of identity that consists of relationships to other persons as well as institutions, practices and beliefs. For Asian women (and perhaps men), the fluid identity is embedded in dynamic societies that continue to negotiate deep-rooted cultural norms with socioeconomic development. It can be argued that cosmetic surgery results from or, at the very least, reflects on-going social changes. As society continues to change and modernise, so does identity. Furthermore, we argue that identity should not only be understood as fluid and in a state of flux (Holliday and Elfving-Hwang 2012; Kim 2003), but should also be seen as transformational. Describing identity as fluid merely implies a passive change of identity that coincides with changes in the wider social context; while considering it as transformational indicates an active and intentional choice. Empirical investigations demonstrate that women's motivations to undergo cosmetic surgery include desire for improved socio-economic opportunities, such as getting married or being employed or promoted. Luo (2013) and Yang (2011) even clarify that cosmetic surgery has allowed women to become not just mere labourers but also consumers in a male-dominant society. Thus, identity should be considered transformational as it reflects a woman's progression from the traditional image to the modern-and her advancement from the domestic to a more globalised culture. From cultural imperialism to cultural nationalism In using relational conception of identity, we posit that ethical reflection of cosmetic surgery of ethnic features should be considered as interplay of cultural imperialism and cultural nationalism that both seem to influence Asian societies. For authors who defend what we would refer to as cultural nationalism, cosmetic improvement of racial features does not merely imply borrowing beauty from another group nor does it mean abandoning one's Asian identity (Davies and Han 2011; Holliday and ElfvingHwang 2012; Lam 2002; Luo 2012). In fact, many Asian women tend avoid obvious alterations that make them appear unnaturally Western. Some authors even argue that cosmetic surgery is within the boundaries of female identity established by cultural norms and traditions in a patriarchal Asian society (Kim 2003). As we previously discussed, Neo-Confucian teachings that are present in varying degrees in East Asian countries define the role of women in reference to their interpersonal relations. Kim, (2003) and Karupiah (2012) claim that female identity is embedded in her body, which is treated as a means to establish a family by forming intimate relationships and bearing children. For this reason, such cultural norm seems Borrowed beauty? Understanding identity in Asian facial cosmetic surgery 123 to dictate women more than men to focus on their bodies, making women more susceptible to seek bodily improvements or cosmetic modifications. Based on a relational interpretation of identity, we argue that both cultural imperialism (westernisation) and cultural nationalism among Asians can be equally influential in shaping identity and are both potential sources of pressure to align to certain standards of beauty. Cosmetic surgery practices do develop within the socio-cultural evolution of a society from the perspective of its own cultural patterns and paradigms, but these cultural patterns are also influenced by Western traditions. The scope now is widened beyond the question whether westernisation of beauty is unethical and inherently oppressive, toward the question whether any type of social pressure (be it of either Western or Asian origin) to align to a specific standard of beauty is. Based on this discussion, we proposed to shift the conception of Asian identity in the context of cosmetic surgery from rigid and individualistic to relational, as well as fluid and transformational. We believe that the relational and dynamic conception of identity reflects changing social contexts that continuously negotiate deeply rooted cultural norms with socio-economic progress. In addition, we argued that identity in cosmetic surgery of Asian features require considering both cultural imperialism and cultural nationalism as potential sources of motivation for women to seek cosmetic surgery. Limitations and recommendations This study has limitations in outlining the specific differences in the context of cosmetic practices among China, Korea and Japan for a number of reasons. Firstly, the language criterion precludes local studies written in Korean, Chinese or Japanese that could provide more comprehensive discussion by local scholars. Second, articles often refer to Asians in general especially in discussing the differences between Asian and Western contexts. These limitations highlight the need for more collaborative studies and academic exchanges with local scholars. Future research could also conduct in-depth comparative studies on the differences and similarities of China, Korea and Japan on the issue of cosmetic surgery. The study also has shortcomings in providing considerable discussions on two important groups of people: cosmetic surgeons and male consumers. Most of the articles included hinge the debate on the perspective of female consumers, thus the strong arguments on feminist frameworks. Future empirical research and ethical studies on these groups would greatly benefit the ethical reflection and discussions on facial cosmetic surgeries in Asians. Conclusions The body of literature on cosmetic surgery practiced in Japan, China and Korea brings up key issues in understanding the debate on modifying ethnic features of Asian women. Major themes mainly include discussion of the westernisation critique that depicts cosmetic surgery as an affront to authentic (ethnic) identity; and identification of cultural and socio-economic motivations behind the popularity of cosmetic modifications of facial features. Despite the rich discussion in published debate on cosmetic surgery among Asians, we argued that articles tend to limit the concept of identity on a highly individualistic interpretation of autonomy. Instead, we proposed to understand identity in this context as relational for two reasons. First, Asian women's identity is deeply embedded in social (familial) relationships. Familial relations often influence decisions, whether in the form of women having cosmetic surgery to have a better chance at marriage or parents financially supporting the cosmetic procedures of their children. Second, Asian women's identity is both fluid and transformational, reflecting a constantly evolving social context. The literature shows that cosmetic surgery in Asians may be less about the ideal face and more about showcasing women as consumers, symbolizing the shift of their role from the traditional to the modern. Furthermore, we argued that westernisation or the cultural imperialist framework is not the only, and even not the most important, motive for women who choose to alter their appearance through cosmetic surgery. In using the relational concept of identity, ethical reflection of cosmetic surgery of racial features should be considered as an interplay of cultural imperialism and cultural nationalism that both seem to influence Asian societies. Both can be a source of social pressure that may exacerbate a culture of oppression against women despite the promises of cosmetic surgery. Acknowledgments The authors would like to thank Professor Pascal Borry and Professor Paul Schotsmans for their guidance in writing this article. 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