Working-class Egyptians are getting botox, breast implants and tummy tucks in the hopes that the cosmetic surgery once reserved for a wealthy elite will boost their own marriage and job prospects.
Illiterate housewives fearing abandonment, soldiers mocked for flabby chests and overweight women struggling to find a husband sometimes pay with their own blood, rely on charity, borrow money from family and friends or turn to unlicensed cut-price private clinics for a procedure.
The extra business from the poor is boosting the experience of Egyptian cosmetic surgeons and lowering the cost of operations, helping Egypt compete with rivals such as Lebanon and Tunisia in the growing market for medical tourism.
Egypt's top cosmetic surgeons say good surgery that improves self-esteem among the wealthy can mean much more to the poor. But they also warn patients to beware of the growing number of cheap clinics which make false promises and botch operations.
"The poor, particularly those who go to university hospitals, help in increasing the experience of new-generation surgeons because they get trained, so the poor are definitely part of the plan," said Rafaat Gohar, former president of the Egyptian Society of Plastic and Reconstructive Surgeons (ESPRS).
Though expensive by local standards, plastic surgery costs a quarter of the price in the United States or Europe, Egyptian doctors say. Botox to treat wrinkles costs 1,600 Egyptian pounds (US$278) compared to nearly US$900 elsewhere. Gohar said tummy tucks cost 20,000 pounds, a third lower than in Gulf Arab states.
Poorer locals who forego a private recovery room and opt for a ward housing several patients, pay even less for treatment.
"Egypt compared to the (United) States and Europe is a quarter of the price and with the same capabilities, if not better," Gohar said.
"We are the hub of the Middle East in plastic surgery. We are even better than Lebanon in terms of number and quality of doctors… It's (Lebanon's) marketing and patient privacy that makes foreigners go there."
With image so vital to the industry's success, top Egyptian surgeons are worried about the cheap, unlicensed clinics that have sprung up in the country to cater for less wealthy clients.
Patients have suffered burns from chemical peels, nerve damage in facelifts and crooked noses from failed nose jobs, said a surgeon who corrected problems incurred from private work gone wrong and asked not to be named.
Another doctor, Mohamed Zaky, said he fixed badly done operations on various parts of the body on a daily basis.
"I pity the poor patient because he goes for plastic or reconstructive surgery for the better, only to come out with results that are not good," Zaky said.
Plastic surgery is a big draw for poorer Egyptian women as men are usually the breadwinners and women often cannot read and are unskilled, making it vital to find and keep a husband.
Marwa, a 22-year-old unemployed woman who weighed around 136 kg, underwent liposuction on her thighs when successive diets failed. She said she needed to find a husband after breaking off a four-year engagement.
"I would see billboards of female Arab pop stars who went under the knife and wished I could have the means they have to look beautiful," she said. Doctors at a state hospital removed 12 liters of fat from Marwa's outer thighs.
She gave them 350 ml of her blood and 350 pounds for a post-surgery belt, paid for with her savings and loans from family and friends.
A few weeks later, as the pain was receding, Marwa received an offer of marriage and her satisfaction was mixed with fear: "If we get married, will he still love and respect me if he ever found out I had plastic surgery?"
A taxi driver said he had planned to divorce until his wife had a breast reduction. At first he regretted pushing her to have the operation as he was left to mind the kids and house.
"I shouted at the doctors to release her before the due date because the house was a total mess and our triplets were left alone all that time," he said, speaking at a university hospital where his wife was having a check-up after surgery.
"But last August, her breasts were drooping and had no form. Now they are firm," he said, asking that his name was not published. He said the operation was free apart from a post-surgery bra costing 180 pounds.
Some operations are paid for by charitable donations, others carried out by private surgeons for free.
"The rich have their money to support them but the poor only have God to support them… I take enough money from the rich to spare some for the poor," said Alaa Gheita, a plastic surgeon who gives lectures on "Plastic Surgery Rights for the Poor".
Hospitals often perform cosmetic surgery for no charge to ensure trainee staff take part in enough operations to earn international recognition, one teaching professor said on condition of anonymity.
Some patients requesting cosmetic surgery are asked to donate blood, part of it used during the operation and the rest added to the hospital's blood bank for other procedures such as emergency operations, said another cosmetic surgery professor who also asked not to be named. He said hospitals often had a shortage of blood.
Abdel Rahman Shahin, a spokesman at the Health Ministry, said patients could be treated by a trainee surgeon for free as long as the operation is supervised by a senior doctor.
He said patients could not be obliged to donate blood, adding: "This should be voluntary and no one can force a patient to donate blood in exchange for surgery."
Cheap, unlicensed clinics charge as little as 4,000-6,000 pounds for breast enlargements and 1,000-2,000 pounds for liposuction.
Some private clinics make false promises such as curing baldness or fattening skinny legs. Misleading "before and after" photos exploit a widespread lack of medical knowledge and hospital doctors have warned potential clients to think twice.
The government has shut 10 percent of private cosmetic surgery centers for lacking a license, but many have found a way to reopen, according to Health Ministry spokesman Shahin.
"They have good lawyers, good connections with retired policemen, simply following the 'Wasta' (connections) culture to get their way," said Gheita.
