The Reasons Behind the Trending of Facial Plastic Surgery in Saudi Arabia

Background: Nowadays, the demand of plastic surgery has dramatically increased According to the American Society of Plastic Surgery (ASPS), nearly 17 million cosmetic producers were performed in 2016 and 58% has increased cosmetic surgery from 2012-2016 for both men and women. Media influences, medical advancements and patients’ characteristics have a role in the recent upsurge of cosmetic surgery.


Introduction
Nowadays, the demand for plastic surgery has dramatically increased [1]. According to the American Society of Plastic Surgery (ASPS), nearly 17 million cosmetic producers were performed in 2016 making the total annual cost of cosmetic procedures around 16.4 billion USD) [2]. According to a study conducted by the International Society of Aesthetic Plastic Surgeons (ISAPS), Saudi Arabia ranks 29 th among the top 30 countries with the highest rates of cosmetic procedures in the world [3]. Cosmetic surgery has increased by 58% from 2012 to 2016 for both men and women [4].
ASPS reported that most of the cosmetic procedures, about 92%, were performed on a female and rhinoplasty was among the top five procedures done in 2015 to 2016 [2]. Multiple factors behind the trending of facial plastic surgery. Media influences, medical advancements, and patients' characteristics have a role in the recent upsurge of cosmetic surgery [5] Exposure to media and satellite television found to be contributing factors to the higher rate of rhinoplasty [6]. Furnham et al. reported that increased media exposure, low self-steam and life satisfaction would increase the chance of undergoing plastic surgery [7]. Also, interaction with surgeons and take consultations through the social media led to an increase in the number of patients searching for plastic surgery [8,9]. According to a poll by the American Academy of Facial Plastic and Reconstructive Surgeons, 42%of surgeons reported patients seeking cosmetic procedures to look better in selfies [10]. Taking selfies and sharing them on social media like snapchat or Facebook has increased recently [11]. A study reported by Ward B et al. showed that nasal size in selfies appears bigger by 30%; therefore, this may be one of the reasons behind the increased demand on rhinoplasty [12]. Another study conducted in Iran by Rastmanesh R et al. [13] showed patients who had a history of cosmetic rhinoplasty have depression and body dissatisfaction with low selfsteam compared with those who did not have a history [13]. The lack of research in this field in our region and the Middle East has prompted us to undertake this study. We aimed to assess reasons of increasing plastic procedures in our community, the effect of social media in this decade and factors motivating people to undergo cosmetic procedures.

Method
A cross-sectional study was conducted in a facial plastic clinic at King Abdulaziz University hospital after the approval of the Ethical Committee of the faculty of medicine at King Saud University, Riyadh, Saudi Arabia. All 18 years of age and older who attended the facial plastic clinic for a procedure, male and female, from January to March 2018 were included. Patients who refuse to be involved in the study were excluded. Anonymous paper-based questionnaires, an electronic-based questionnaire was distributed to people who attend cosmetic clinics. The sample size was determined by using a single population proportion sample size. Estimation method with 95% confidence interval. The questionnaire was translated to the Arabic Language. The questionnaire contained four parts; first part is about socio-demographic data which included ten close- Fisher's Exact Test was used to determine the statistical difference between categorical groups or proportions. A p-value of less than 0.05 was considered statistically significant.  Table 1). The association between the financial status & the facial plastic surgery was found to be statistically significant. The participant who is independent shows higher desire to go for facial plastic surgery (p-value:0.021) ( Table 2). In our population, the most common cosmetic intervention was Botox injection (41%), and the most common facial plastic procedure was rhinoplasty (59%). We measured the frequency of taking selfies and the association with the desire to do a facial plastic intervention. surprisingly, the majority (85%) did not take regular selfies (>3 times\day). Moreover, there was no statistically significant associated with the desire to go for plastic intervention (p-value: 0.505) ( Table 3). Currently, everyone relates the trending of facial plastic intervention to the era of advertising & social media. As reasons our participants thought that what makes the facial plastic intervention trending in our population are:

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Copyrights @ Almuhaya Reham, et al.   a) The effect of social media influencers and celebrities believe that self-portrait caused more awareness of the appearance of the face/nose (Table 4).  (Table 7).   surgery, multi studies reported that to look more beautiful is the primary motivation [14,16]. Another study done in al-Madinah said that 46% who had plastic surgery believe that social media affected their decision [14]. In another study, the primary motivating reason to have plastic intervention is influenced by family and friend (40%) [17]. In contrast to our finding, Forty-two percent surgeons reported patients seeking cosmetic procedures to look better in selfies [10]. In our study, the overall prevalence of positive BDD in patients who had or are planning to have cosmetic surgery was about 20.5% [18]. Like multi-centric prospective study that assessed the prevalence of BDD among facial plastic and oculoplastic surgery patients in 3 sites, including academic practice and private practice, showed a prevalence of positive BDD around 37%, 13%

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in academic and private practice respectively [17]. A meta-analysis of 33 studies evaluate the prevalence of body dysmorphic disorder in plastic surgery, and dermatology patients report that 15.04% of plastic surgery patients were positive BDD [19].