Attitudes and acceptance of the Saudi population toward cosmetic surgeries in Riyadh, Saudi Arabia.

CONTEXT: Public awareness regarding cosmetic surgery. AIMS: To assess the attitudes and acceptance of cosmetic surgery among patients in a tertiary care hospital in Riyadh, Saudi Arabia. SETTINGS AND
DESIGN: Single-center, cross-sectional study in the family medicine department at our institution. METHODS AND MATERIAL: Data were collected from 389 patients (age 15-50, 29.37 ± 9.25 years, male: female = 139:250) using the Acceptance of Cosmetic Surgery Scale (ACSS) modified for Arabic speakers. STATISTICAL ANALYSIS USED: SPSS 22 statistical package.
RESULTS: One hundred eighty-five (47.6%) patients were willing to undergo minor cosmetic surgery, whereas 144 (37.1%) were not. Additionally, 237 (60.9%) patients agreed that cosmetic surgery is good because it can help people feel better about themselves, whereas104 (26.8%) patients disagreed. Robust Cronbach α values were observed among all ACSS scales. Mean significant (P = 0.002) differences were observed between gender and the intrapersonal scale scores. The average intrapersonal scale score was greater among female patients (22.48 vs. 19.29). Similarly, the mean consider scale scores among female patients (20.92 vs. 17.45; P = 0.001). Mean significant (P = 0.001) differences were also observed between education and the intrapersonal scale.
CONCLUSIONS: The results reveal important information regarding the acceptance of and attitudes toward cosmetic surgery in Saudi Arabia. There is an urgent need for regulatory intervention to ensure patient safety and satisfaction.

Introduction

Cosmetic surgery is a subspecialty that deals primarily with the preservation, rebuilding, or improvement of the physical appearance of an individual through surgical and therapeutic methods. Over the past 10 years, there has been a huge increase in the number of cosmetic surgeries worldwide.[1]

According to the American Society for Aesthetic Plastic Surgery, approximately 8.3 million cosmetic surgical and nonsurgical procedures were performed in 2003. These values represent an increase of 299% between 1997 and 2003, and the number has further increased in the last decade. Patients seeking cosmetic surgery are generally assumed to be older women attempting to turn back time. The typical patient, however, is significantly younger; 45% of all patients undergoing cosmetic surgery are aged 35-50 years, and 27% are under 35 years.[23]

Three features are likely to play a role in the current expansion of cosmetic surgery. These aspects include medical advancements, patient characteristics, and media influences. For many years, mass media has been recognized to have a huge influence in determining both personal appearance and hypothetical decisions regarding cosmetic surgery. For decades, the public has imitated the hairstyles, clothing, and body types of the famous, and as a result, many studies have estimated that mass media influences, such as magazines, TV shows, and movies, may affect body image satisfaction and self-esteem.[45]

In spite the wonderful advances in the field of plastic surgery, the knowledge regarding the field among the general public remains inadequate, especially regarding cosmetic surgery. It also remains unclear whether the medical community is well-educated about cosmetic surgery. The knowledge of the public about cosmetic plastic surgery will increase in proportion to the knowledge of the health workers who are likely to inform or misinform the public about these surgical procedures. These people contribute significantly to public health care.

This study is an attempt to determine the knowledge of the patients in Saudi Arabia at the national level about cosmetic surgery and their attitudes. However, there might be a low level of knowledge and attitude toward cosmetic surgery among patients because of insufficient understanding and lack of awareness.

Cosmetic surgery was previously prohibited and considered to be religiously unaligned in Saudi Arabia. The public was against cosmetic surgery because of the health risks and religious views regarding restorative surgeries. However, the general attitudes about the risks and safety of the procedure have improved with the introduction of innovations and techniques as well as advice and recommendations from family and friends.

According to the American Society for Aesthetic Plastic Surgery, expenditures for both surgical and nonsurgical procedures are increased by 1.5 billion dollars from 2014 to 2015. Surgical procedures accounted for 58% of the total expenditures in 2015, whereas nonsurgical procedures accounted for 42%.[6]

Agbenorku (2013)[7] conducted an observational study to determine the level of awareness and attitudes toward facial plastic surgery and organ transplants. Few (33.5%) respondents were familiar with face transplants; 70.0% and 62.1% were willing to undergo a face transplant if their face was disfigured or were willing to donate their face when dead, respectively. Additionally, 50.6% were familiar with organ transplants. Conclusively, face and organ transplants were found to have relatively low and high awareness levels, respectively. However, a positive attitude was recorded for face and organ transplants. More education on face and organ transplants is needed.

Antoszewski (2012)[8] conducted a study on the perception of plastic surgery and its influence on referrals. Respondents were asked to complete a questionnaire containing questions regarding conditions for which plastic surgery treatments were reimbursed. Fifty-eight primary care physicians responded: 30 specialists in family medicine and 28 residents in the final year of their specialization in family medicine. Respondents had a good knowledge regarding the range of the conditions encountered in plastic surgery. Categorically, the improvement of needs and collaboration between plastic surgeons and family physicians to provide basic knowledge regarding plastic surgery should be included in residency programs in family medicine.

Another cross-sectional study in 2011[9] aimed to measure the prevalence and desire for body contouring surgery after bariatric surgery patients in Saudi Arabia. The results showed that 78.1% participants wanted to undergo cosmetic surgery (body contouring). However, only 14% participants underwent the surgery. The study did not indicate why most of the patients who wanted to have surgery did not.

Subjects and Methods

Study design

This cross-sectional study was conducted in the family medicine clinic at a tertiary care hospital in Riyadh, Saudi Arabia. The study protocol was approved by the Ethical Committee and Institutional Review Board at our institution.

Study population

The target population of the study was chosen from the patients attending the family medicine clinic at our institution. All male and female patients who could read and write and aged 15-50 years were included in the study.

Data collection

All patient data were collected using a validated questionnaire from the Acceptance of Cosmetic Surgery Scale (ACSS; Henderson-King and Henderson-King 2005) modified for Arabic speakers.[10] ACSS is a 15-item scale that measures the acceptance of cosmetic surgery for social and intrapersonal reasons (Henderson-King and Henderson-King, 2005). ACSS has three subscales: (1) Intrapersonal, which assesses whether an individual would have cosmetic surgery for self-oriented benefits, e.g. “Cosmetic surgery can be a big benefit to people's self-image”; (2) Social, which measures whether an individual would undergo cosmetic surgery for social reasons, e.g. “I would seriously consider having cosmetic surgery if my partner thought it was a good idea”; and (3) Consider, which assesses whether an individual would consider undergoing surgery for general reasons under various scenarios, e.g. “If I could have a surgical procedure done for free I would consider trying cosmetic surgery.” Responses were reported on a 7-point scale (1 = strongly disagree, 7 = strongly agree), with higher scores indicative of greater endorsement of cosmetic surgery. Subscale scores were computed by taking the mean value for items associated with each subscale. The total score referred to as acceptance was computed by calculating the mean across all items. ACSS has demonstrated high internal consistency, and the Cronbach's alpha across four validation studies was 0.84-0.92 (Henderson-King, and Henderson-King, 2005). As noted above, ACSS was translated into the Arabic language for the purposes of the current study and scored in the same manner as the English version.

Sample size and sampling technique

The sample size was calculated using sample size software for prevalence studies[11] considering 50% knowledge and attitude toward cosmetic surgery and using a 5% margin of error and 95% confidence interval. Non-probability convenience sampling indicated an estimated sample of 389 patients for this study would have 80% power for the test to detect differences at a two-sided level of significance.

Statistical analysis

Categorical variables such as gender, age group, and marital status were presented in frequencies and percentages. Continuous variables such as age and ACSS scales were presented as mean ± standard deviation (SD). The Cronbach α test was employed to assess the internal consistency of the ACSS. An independent sample t test/analysis of variance test was used to determine the mean significant differences between the study characteristics and ACSS scales. Data were entered and analyzed through the statistical package SPSS 22 (SPSS Inc., Chicago, IL, USA).

Results

The current study included 389 family medicine patients selected by non-probability convenience sampling and interviewed to determine their attitudes toward cosmetic surgery. Demographic information for the participants is provided in Table 1. The number of women in the study (250,64.3%) was greater than that of men (139,35.7%), and the average age of the patients was 29.37(±9.25) years. Two hundred and thirty-seven (60.9%) patients agreed that cosmetic surgery is a good thing, whereas104 (26.8%) patients disagreed [Tables 2-4].

Table 1

Basic characteristics of the patients (n=389)

Characteristics		n (n%)
Gender	Male	139 (35.7%)
	Female	250 (64.3%)
Age (years)	Mean±SD	29.37±9.25
Education	School	176 (45.2%)
	College	213 (54.8%)
Marital status	Single	191 (49.1%)
	Married	175 (45.0%)
	Divorced	18 (4.6%)
	Widowed	5 (1.3%)

Table 2

Questionnaire responses to first 15 scale items (n=389)

Scale items	Strongly disagree	Disagree somewhat	Disagree a little	Neutral	Agree a little	Agree somewhat	Strongly agree
It makes sense to have minor cosmetic surgery rather than spending years feeling bad about the way you look.	70 (18.0%)	45 (11.6%)	29 (7.5%)	60 (15.4%)	66 (17.0%)	48 (12.3%)	71 (18.3%)
Cosmetic surgery is a good thing because it can help people feel better about themselves.	40 (10.3%)	28 (7.2%)	36 (9.3%)	48 (12.3%)	66 (17.0%)	76 (19.5%)	95 (24.4%)
In the future, I could end up having some kind of cosmetic surgery.	110 (28.3%)	30 (7.7%)	33 (8.5%)	63 (16.2%)	45 (11.6%)	58 (14.9%)	50 (12.9%)
People who are very unhappy with their physical appearance should consider cosmetic surgery as one option.	70 (18.0%)	41 (10.5%)	45 (11.6%)	53 (13.6%)	67 (17.2%)	56 (14.4%)	57 (14.7%)
If cosmetic surgery can make someone happier with the way they look, then they should try it.	79 (20.3%)	29 (7.5%)	38 (9.8%)	66 (17.0%)	65 (16.7%)	51 (13.1%)	61 (15.7%)
If I could have a surgical procedure done for free, I would consider trying cosmetic surgery.	110 (28.3%)	32 (8.2%)	28 (7.2%)	59 (15.2%)	49 (12.6%)	44 (11.3%)	67 (17.2%)
If I knew there would be no negative side effects or pain, I would like to try cosmetic surgery.	84 (21.6%)	29 (7.5%)	36 (9.3%)	47 (12.1%)	56 (14.4%)	53 (13.6%)	84 (21.6%)
I have sometimes thought about having cosmetic surgery.	96 (24.7%)	23 (5.9%)	37 (9.5%)	46 (11.8%)	73 (18.8%)	50 (12.9%)	64 (16.5%)
I would seriously consider having cosmetic surgery, if my partner thought it was a good idea.	114 (29.3%)	31 (8.0%)	36 (9.3%)	60 (15.4%)	46 (11.8%)	47 (12.1%)	55 (14.1%)
I would never have any kind of plastic surgery.	74 (19.0%)	38 (9.8%)	39 (10.0%)	82 (21.1%)	43 (11.1%)	35 (9.0%)	78 (20.1%)
I would think about having cosmetic surgery to keep looking young.	112 (28.8%)	32 (8.2%)	35 (9.0%)	47 (12.1%)	62 (15.9%)	46 (11.8%)	55 (14.1%)
If it would benefit my career, I would think about having plastic surgery.	89 (22.9%)	27 (6.9%)	30 (7.7%)	49 (12.6%)	50 (12.9%)	50 (12.9%)	94 (24.2%)
I would seriously consider having cosmetic surgery, if I thought my partner would find me more attractive.	104 (26.7%)	35 (9.0%)	36 (9.3%)	51 (13.1%)	45 (11.6%)	44 (11.3%)	74 (19.0%)
Cosmetic surgery can be a big benefit to people's self-image.	64 (16.5%)	28 (7.2%)	40 (10.3%)	46 (11.8%)	67 (17.2%)	57 (14.7%)	87 (22.4%)
If a simple cosmetic surgery procedure would make me more attractive to others, I would think about trying it.	107 (27.5%)	38 (9.8%)	42 (10.8%)	51 (13.1%)	46 (11.8%)	44 (11.3%)	61 (15.7%)

Table 4

Questionnaire responses to scale item 17on future surgeries

Scale items	Description	n (n%)
Q17_Future_sugery_clarify	Liposuction	9 (2.3%)
	Breast enhancement	5 (1.3%)
	Hair transplant	2 (0.5%)
	Blepharoplasty	5 (1.3%)
	Fillers	8 (2.1%)
	Botox	2 (0.5%)
	Laser	0 (0.0%)
	Rhinoplasty	26 (6.7%)
	Nefertiti lift	3 (0.8%)
	Body contouring	19 (4.9%)
	Face lift	5 (1.3%)
	Septoplasty	1 (0.3%)
	Burn repair surgery	4 (1.0%)
	Chin augmentation	2 (0.5%)
	Scar revision surgery	1 (0.3%)
	Tummy tuck	3 (0.8%)
	None	294 (75.6%)

Robust Cronbach α values were observed among all ACSS scale scores, which reflects perfect internal consistency and reliability of all ACSS scores. The average value for the statement “an individual should have cosmetic surgery for its self-oriented benefits” was 21.34(±8.753), which is a significantly high value for the intrapersonal scale scores. The average value for the overall scale was 60.11(±25.117)[Table 5].

Table 5

Descriptive statistics and the internal consistency of ACSS scale items

Scale items	Mean±SD	Cronbach alpha (α)
It makes sense to have minor cosmetic surgery rather than spending years feeling bad about the way you look.	4.12±2.112	0.949
Cosmetic surgery is a good thing because it can help people feel better about themselves.	4.75±1.976	0.951
In the future, I could end-up having some kind of cosmetic surgery.	3.71±2.176	0.948
People who are very unhappy with their physical appearance should consider cosmetic surgery as one option.	4.03±2.058	0.948
If cosmetic surgery can make someone happier with the way they look, then they should try it.	4.04±2.082	0.948
If I could have a surgical procedure done for free, I would consider trying cosmetic.	3.78±2.245	0.947
If I knew there would be no negative side effects or pain, I would like to try cosmetic surgery.	4.17±2.225	0.947
I have sometimes thought about having cosmetic surgery.	3.98±2.179	0.948
I would seriously consider having cosmetic surgery, if my partner thought it was a good idea.	3.65±2.194	0.948
I would never have any kind of plastic surgery.	4.03±2.119	0.956
I would think about having cosmetic surgery to keep looking young.	3.7±2.2	0.949
If it would benefit my career, I would think about having plastic surgery.	4.21±2.281	0.949
I would seriously consider having cosmetic surgery, if I thought my partner would find me more attractive.	3.84±2.264	0.948
Cosmetic surgery can be a big benefit to people's self-image.	4.4±2.121	0.949
If a simple cosmetic surgery procedure would make me more attractive to others, I would think about trying it.	3.69±2.207	0.949
Intrapersonal scale	21.34±8.753	0.831
Social scale	19.09±9.480	0.816
Consider scale	19.68±8.984	0.823
Overall score	60.11±25.117	0.912

There were no mean significant differences observed between age group and ACSS scale scores. On the contrary, mean significant (P = 0.002) differences were observed between gender and the intrapersonal scale scores. The mean value for female patients on the Consider scale (20.92 ± 9.11) was higher than that for male patients (17.45 ± 8.31), and the difference was statistically significant (P = 0.001). Mean significant differences (P = 0.001) were also observed between education level and the intrapersonal scale scores [Table 6].

Table 6

Analysis of the acceptance of cosmetic surgery among the Saudi population

Characteristics	Descriptions	Intrapersonal scale	Social scale	Consider scale	Overall score
Age	≤30	21.47±8.646	19.29±9.507	20.15±9.166	60.91±25.32
	>30	21.12±8.955	18.75±9.459	18.90±8.649	58.77±24.8
	P - value	0.700	0.583	0.180	0.413
Gender	Male	19.29±8.34	18.44±8.74	17.45±8.31	55.18±23.58
	Female	22.48±8.78	19.45±9.86	20.92±9.11	62.85±25.56
	P value	0.002	0.299	0.001	0.003
Education level	School	19.70±8.83	18.13±9.46	18.49±8.98	56.32±25.40
	College	22.69±8.47	19.88±9.44	20.66±8.88	62.85±24.50
	P value	0.001	0.070	0.018	0.007
Marital status	Single	21.27±8.712	18.9±9.424	19.64±9.448	59.81±25.462
	Married	21.66±8.962	19.23±9.738	19.96±8.767	60.86±25.452
	Divorced	20.56±7.617	20.17±8.104	18.5±6.299	59.22±19.869
	Widowed	15.6±6.189	17.2±9.121	15.8±6.979	48.6±18.474
	P value	0.468	0.909	0.703	0.741

Discussion

Our results reveal important information regarding the attitudes and acceptance of the Saudi population toward cosmetic surgery. Overall, 43.9% acceptance of cosmetic surgery was observed among patients. However, the results indicate that appearance-related attitudes predicted the degree to which women accepted cosmetic surgery for social reasons, and this group desired some new cosmetic procedures as well. Our findings were nearly similar to our expectations of a positive attitude and acceptance of cosmetic surgery among the patients.

From our results, women had a significantly higher total ACSS score than men. Markey et al.[12] also reported that women were more concerned regarding cosmetic surgery than men. Similarly, Swami et al.[13] stated that women have greater acceptance of cosmetic surgery. According to Brown et al.,[5] this sex difference may derive from the greater socio-cultural burden on women to obtain the ideals of physical attractiveness and attention.

Our results indicated that ACSS can be used to evaluate internal and external motivations for undergoing cosmetic surgery among the Saudi population. In the present study, intrapersonal reasons were more important than social reasons among both women and men. These conclusions are similar to the results obtained from other studies involving women who reported internal rather than external reasons for undergoing breast-augmentation surgery.[14] Among adults in the United States and Europe, intrapersonal reasons have a greater impact on the acceptance of cosmetic surgery compared with social reasons. In non-Western countries, however, intrapersonal and social reasons have equal influence on the acceptance of cosmetic surgery.[51213]

The data confirmed that the current sample of patients encompassed different age groups and had significant attitudes and acceptance toward cosmetic surgery. In consideration of group mean analysis scores for measures assessing openness toward cosmetic surgery for oneself, women, and men, the participants were overall quite favorable toward cosmetic surgery regardless of their classification and the patients undergoing cosmetic surgery. Furthermore, our results agree with Park et al.'s findings[15] that young adults in the U.S. increasingly hold positive views about cosmetic surgery for themselves and others. This persistent acceptance of cosmetic surgery has been the conventional method in the last few decades in the U.S. Overall, the study demonstrated the value of cosmetic surgery as a means of making individuals feel better about themselves in multiple contexts. Current research suggests that a generational effect that replicates a slightly self-absorbed and young generation may influence the degree of acceptance of cosmetic surgery.

Our study has several limitations. This was a single-center study and, therefore, will not be completely representative of all hospitals in Saudi Arabia. Population proportion sampling can underestimate the error within a sample, and when errors are found, population proportion sampling may overstate the allowance of sampling risk. The study sample was a consecutive series of patients who visited family medicine clinic settings. This group may have different characteristics than the general population during the observed period. Findings obtained in such specific settings cannot be easily generalized to the wider population.

Conclusion

The attitude and acceptance of cosmetic surgery remain low in developing nations. ACSS appears to be a valid instrument for use in Saudi populations. Our study contributes toward better understanding of the acceptance of cosmetic surgery from a cross-cultural perspective.

Author contributions

Conceived and designed the experiment: SAM GW. Performed the experiment: SAM GW. Analysed the data: SAM. Contributed reagents/materials/analysis tools: SAM GW. Wrote the paper: SAM.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Table 3

Questionnaire responses to scale item 16 on past surgeries (n=389)

Scale items	Description	n (n%)
Q16A_previous_surgery	Yes	33 (8.5%)
	No	356 (91.5%)
Q16B_clarify	Filler	3 (0.8%)
	Botox	2 (0.5%)
	Tattoo removal	1 (0.3%)
	Breast enhancement	3 (0.8%)
	Tummy tuck	2 (0.5%)
	Burn repair surgery	1 (0.3%)
	Rhinoplasty	1 (0.3%)
	Liposuction	1 (0.3%)
	None	375 (96.4%)