Personal motivations of Iranian men and women in making decision to do face cosmetic surgery : A qualitative study

Background: Face cosmetic surgery is one of the most common surgeries in Iran; currently, it is popular among men and women. Considering the risk of complications in this type of operations, this question arises that what is personal motives for decision to do face cosmetic surgery? The purpose of this study is to explore personal motivations of decision to do face cosmetic surgery. Methods: This study was conducted using qualitative research and content analysis approach. The studied population included 21 men and women aged 22-52 who had undergone face cosmetic surgery 1-5 years ago. Sampling started with purposive sampling and ended with data saturation. Interviews were used to collect data. All interviews were recorded and transcribed immediately. Data was analyzed using conventional content analysis. Results: Data analysis revealed main theme “personal motivations” that including three main category, feelings of inferiority, Escape from loneliness, and Fear of the unseen. The results of the study showed that feelings of inferiority, Escape from loneliness and Fear of the unseen by relatives and society are the greatest and most important motivations for undergoing cosmetic surgery and accepting the risk of surgeries. Conclusion: Considering the negative physical and mental health implications of cosmetic surgeries, health care providers particularly nurses by community based views can make efforts to change positive attitudes of people and improve psychological insecurities through cooperation of families and educational interventions by understanding the reasons for which people decide to undergo cosmetic surgeries


INTRODUCTION
In recent years, there has been tremendous growth in popularity of cosmetic surgeries (1), particularly face cosmetic surgeries (2).Because people are known by their faces, it is of great importance in social life (3).Cosmetic surgery is an optional surgical procedure with the aim of improving appearance and Change the face which is unpleasant for the person (4).American Society of Plastic Surgeons (ASPS) reported that nearly 11 million invasive and noninvasive cosmetic surgeries have been done in 2013 in the United States; this figure is 6.5% more than in 2012 (5).There are no available official statistics on total number of cosmetic surgeries performed annually in Iran.However, studies show that face cosmetic surgeries, particularly Rhinoplasty, are the most common type of cosmetic surgery in Iran (6).
That is why the International Society of Aesthetic Plastic Surgeons (ISAPS) reported Iran as one of the top ten countries with the highest rates of cosmetic surgery in the world in 2013 (7).With the increasing prevalence of cosmetic surgery in Western societies, it is required to explore various internal and external factors which motivate people to perform cosmetic surgery (8).Sarwer et al. (2003) attributed this recent increase to availability of plastic surgeons, influential media and personal factors related to the patient.They suggested that a lack of awareness is responsible for the increased tendency of people to change their appearance through cosmetic surgeries.This lack of awareness may cause many people have lower life satisfaction because of their physical appearance and tend to change by cosmetic surgery as a result (9).Furnham et al. (2012) reported low self-esteem, life dissatisfaction, feeling of low attractiveness as the greatest causes of motives to perform cosmetic surgeries; in fact, people with incredibly low self-esteem may suffer from depression (8).Swami et al. (2009) showed that people who rank their physical attractiveness lower are more likely to seek cosmetic surgery (10).Schmalz (2010) showed that people who are overweight and not happy with their body shape hate their body and seek cosmetic surgery (11).Markey and Markey (2009) also found that body dissatisfaction, being annoyed by physical appearance and influence of media led to tendency to cosmetic surgery, while body dissatisfaction was the most predictive of interest in cosmetic surgery (12).Through a qualitative study, Reardon et al (2016) reported pain, negative body image and low self-esteem as women's reasons for cosmetic breast surgery (13).
Seemingly, people believe that face beauty is completed with surgery, while surgery sometimes not only does not cause significant changes in their appearances but also leads to loss of raw beauty and even lives (14).Although face cosmetic surgery is generally considered as a safe procedure, many studies reported the incidence of its complications varying from 4% to 18.8% (15).This decision in turn underlies a problem known as paradox of health value and aesthetic value (16).So not only should be considered as a social problem, but also a medical subject.
High costs are spent annually for cosmetic surgeries and pre-and post-operational cares, leading to a large financial burden on economy, healthcare system and particularly nursing system (17); as estimated, 160 billion riyals are spent annually on plastic surgeries in Iran (18).
Face cosmetic surgeries are not emergency surgeries and may be associated with dangerous consequences.Therefore, the question arises that why many people turn to perform these operations despite these risks?What problems had these people?And why and how they convince themselves to do cosmetic surgery.These questions which are related to experiences of people about a particular event cannot be answered with quantitative methods; instead, they need to be evaluated qualitatively.Considering the popularity of face cosmetic surgeries and potential complications and risks of these operations, it seems essential to conduct a study on applicants for this type of surgery; then, personal motivations for having cosmetic surgery are identified based on their own stories.

Study Design
In this qualitative study in order to identify personal motivation influencing the decision to undergo face cosmetic surgeries was used content analysis.Content analysis refers to subjective interpretation of the text content by categorizing the codes regularly and identifying themes or patterns (19).Content analysis is based on inductive reasoning with conventional, direct and evolutionary approaches.According to in this study, the aim was to describe the personal motivation influencing the decision to undergo face cosmetic procedures, the conventional approach was used for analysis.This approach designed to describe a phenomenon and researcher instead of using pre-determined classifications, the use of names and classes derived from data and finds a new insight with close connection to data (20).The approach developed by Graneheim and Lundman (2004) was used for data analysis.This approach involves several studies of data to get a general sense, transcription of interviews verbatim, division of the text into summarized semantic units, abstraction of the summarized semantic units, labeling by codes, separation of codes in sub-themes by comparing them based on their similarities and differences, and set of themes as marker of hidden text content (21).

Participants
Data were collected between the years of 2014 Up to 2015.Were selected 21 participants (7 men and 14 women) living in West Tehran, Iran, who had undergone face cosmetic surgery one to five years ago.Personal Characteristics of the Participants listed in Table 1.
Inclusion criteria included: face cosmetic surgery performed under general anesthesia, at least three months past their surgery, available addresses and phone numbers, completely vigilant at the time of data collection, and tendency to participate in the study.Although the samples were geographically and culturally homogeneous, it was tried to include qualified individuals with maximum diversity in terms of age, gender and type of cosmetic surgery.

Interview Guide
In-depth interviews and semi-structured questions were used for collecting data.The main questions asked of participants included: 1) how did you feel about yourself before the surgery?2) why did you decide to do this surgery?Considering the experiences of participants, other in-depth questions were asked depending on each participant to understand the experiences fully.To increase depth of interviews, probing questions like 'What do you mean?' 'Explain' and 'Give an example' were used.

METHOD
This study was part of a larger study to Explaining the Decision-making process, in Individuals undergoing face Cosmetic Surgery.Approved by the Research Council and the University Ethics Committee (Code of Ethics: K/93/241, adopted on October 04, 2014), the author was initially referred to department of medical records in a cosmetic surgery center to obtain the lists of names and telephone numbers of people who had undergone surgery in this center and select them objectively.By telephoning the participants, objectives and procedure of the study were explained and time and place of interviews were arranged, if accepted.Interviews were mostly done at workplace and at home with a few in the park.Interviews lasted for 45-90 minutes.Interviews were recorded by MP3 Recorder with the permission of participants.Three interviews were performed in two sessions; the remaining interviews were performed in one session.
The criterion of Guba and Lincoln (1985) was used to ensure trustworthiness of the study; prolonged contact with the subject, participant review and peer review were used to validate the study.The encoded interviews were returned to five participants to determine whether the authors demonstrated their views.Through peer review, transcribed and interpreted interviews were given to a number of qualitative researchers who discussed about accuracy of interpretations.The procedure, necessary changes made in the process as well as documentations was recorded to determine reliability of the study.Moreover, all documentations including audio and text files derived from interviews were stored to allow referral, if necessary, and repeatability of the study.To determine transferability of the study, findings were presented to some women and men who were eligible for the study to confirm consistency of the extracted concepts with their experiences.

Analysis
Data collection and data analysis were conducted at the same time.For this purpose, a five-stage method suggested by Lundman and Graneheim was used for analyzing qualitative data.First, the interviews were handwritten and studied several times to achieve a general understanding of participants' talks with regard to the objectives.Then, the words, phrases, sentences and even paragraphs were considered as semantic units; then, initial codes were extracted.The similar codes were classified; then, the categories were merged in a pyramid structure for abstraction.Main categories which represented more abstract concepts were formed.Interviews ended when the themes emerged and data was saturated.Finally, the main theme involving several main categories and several sub-categories were extracted from data; interpretation and conclusions were made based on the themes derived.

RESULTS
The main theme extracted was "personal motivations" consisting of 3 sub-categories including the feelings of inferiority, escape from loneliness, and fear of the unseen and several sub-categories.Table 2 lists main categories and sub-categories.

Category 1: Feeling of Inferiority
Feeling of inferiority is the first category of the main theme in experiences of participants; this category includes two sub-categories: 1) negative body image, and 2) low self-esteem.This category briefly shows that negative self-image can lead to dissatisfaction and unhappiness and cause preoccupation for many days to the extent that, having negative self-image causes many stresses and finally leads to perform surgery as a way to escape.
In response to the question that why you decided to undergo cosmetic surgery, a participant said: "When I saw myself in the mirror, I felt I have a big nose ... it considerably affected my face.I felt that nobody looked at me...I was depressed" (male, 22 years old, single, bachelor and self-employed).
Another participant said: "when I saw myself in the mirror I did not feel beautiful.I could not like myself.I felt I am a simple girl that her ugliness is more than her beauty; Because of this I found problem mentally (female, 26 year old, single and student).
Confidence was remarkably emphasized in the study.In this category, it becomes clear that the problem of confidence is one of the leading causes of cosmetic surgery among women and men.They seek ways to increase their confidence.Participants noted that they suffered from lack of confidence and tended to become more beautiful and increase their confidence by surgery.
A participant said: "I remember I was walking out the college with my friend and some boys were teasing us ... they were saying nose job costs nothing right now, let us lend you money for your nose job… Well, this destroyed my confidence" (female, 26 years old, married and graduate student).
Expression of ugliness by others can suppress the confidence that one collects from childhood; this may not even be compensated from other sources."A close relative told to my father: Send your daughter to nose surgery so she could find someone for herself!Maybe I laughed at that time; but it was internalized in my subconscious… It was all because of, I had no confidence and there was no one to give me the confidence" (female, 26 years old, married and a graduate student).
Lack of enough confidence for social participation encourages people to do cosmetic surgery.Participants considered beauty as a fundamental element of social participation.One of the participants said: "better appearance can bring confidence and make people feel more comfortable and confident with others ... I lacked this confidence...." (male, 26 years old, single and a graduate student).

Category 2: Escape from loneliness
Escape from loneliness encompasses the conceptual notions of "feeling of inner void", "feeling of a lack of love in life ", and "lack of misery business".Loneliness is a feeling of emptiness and inner void.From perspective of interviewees, people undergo expensive and dangerous surgeries to relieve from exhaustion and inner void which they feel.A participant said: "Everyone feels a loneliness within itself ... I thought there was a gap in my life ... I was tired of myself ....I thought maybe cosmetic surgery make a change in my face" (female, 33 years old, married, bachelor and housekeeper).
Some also consider cosmetic surgery as a way through which they can cover their inner weaknesses.Another participant said: "We feel a series of weaknesses, we want to resolve these weaknesses with appearances ... we want to cover those weaknesses with surgery ...Although it is inner weakness, we want to cover it as it does not exist ...." (male, 27 years old, graduate and lecturer).Some people emotionally feel empty and alone.Some participants said that feeling of a lack of love in life causes excessive attention to appearance; they would never tend to undergo cosmetic surgeries if they received sufficient love from spouse and family.A participant said: "There was no one to love me; my husband's family are a family without love.... lack of love caused me to get the surgery ...." (female, 33 years old, married, bachelor's and housekeeper).
Another participant said: "My husband did not love me ... I told him to love me so I do not do the surgery so that someone else confirmed to me ... we do surgery to get others' appreciation; well, this results from lack of love ... if you feel sufficient love, you will not do surgery ..."(female, 34 years old, divorced and housewives).
Some believe that lack of love roots back to childhood within the family.Lack of love from family leads to demoralization, suppression of confidence and internal deficiencies in adulthood and thus tendency to do cosmetic surgery.One of the participants said: "everything goes back to the our past … because we have been too many children, our parents did not support us enough ... they were not loving ... no one had time to get someone to love ... this lack of love now has lowered our confidence ... it led to deficiency ... it influenced our behavior today" (male, 26 years old, diplomas and single).
Loneliness and idleness would lead to the tendency of people to manipulation of appearance.Participants stated that they would pay less attention to appearance if they had Misery Business.A participant said: "I was unemployed at the time ... I had nothing to do; I looked at myself in the mirror...I found more defects in my face... this led me to do cosmetic surgery ... but when you're busy, we spent less time in front of the mirror ..." (female, 24-year-old, single, student).
Another participant said: "I have been a soldier for 17-18 months.This is an engagement, I have not been thinking about surgery....But this is 1 month that I went to where I do not do anything...It caused which I Leave Of thought working and Surgery became important for me..." (male, 22 years old, married, diploma and soldier).
Therefore, feeling of inner void, feeling of lack of love in life and lack of misery business play a key role in development of thought about appearance and thus cosmetic surgery among the participants.

Category 3: Fear of the unseen
Fear of the unseen is involves "fear of being compared "and "fear of losing attention".In the social space, evaluation is based on comparison with others in various areas, which leads people to evaluate themselves as beautiful or not beautiful.Among those who were married, the main reason for cosmetic surgery was fear of being compared.Married participants felt that their husbands indirectly compared them with more beautiful and perfect women.Being compared by their husbands was a cause of concern and preoccupation of married women.A participant said: " In a society that everyone to handle their appearance...I think my husband see them and says wow! look at this beautiful girl … why my wife is not like them ….You know, they compare" (female, 33 years old, married, bachelor's and housekeeper).
It is believed that beautiful face will be accepted; otherwise, people will lose attention of friends and peers, community and even family.Participants know the fear of losing attention of relatives as a motive for cosmetic surgery.
A married participant said: "I wanted to be accepted by my husband ... I'm afraid to lose my husband's attention so, I do everything...." (female, 37-year-old, married and employed).
Fear of aging is a general fear, involving both men and women.People believe that aging destroys beauty.People in modern societies are evaluated based on their beauty; naturally, people avoid aging, because they think they will not be seen if they are old.On the other hand the fear of losing attention of parents, spouse and children can help a sense of emptiness and tendency for cosmetic surgery.
A participant said: "I do not like to get old early ... I do not like to lose today....I do not want to lose the attention of those around me...I want to be with my children" (female, 52 years old, married and housewife).

DISCUSSION
Currently, beauty has become a new interaction for Iranians.Cosmetic surgery can be more a personal motivation that it is an indication self-control and independence (22).
This study showed that feeling of inferiority, Escape from loneliness and Fear of the unseen are personal motivations which led people towards cosmetic surgery.Experiences of participants indicated that they were unhappy with discord and disproportion of their face; they considered themselves ugly before their surgery and stated that because of this Ugliness, they suffered from mental problems including stress and depression.Feeling of inferiority involves two subcategories" negative body image" and "low confidence" ; Results of present study was consistent with some other studies in other cosmetic surgery.Researchers reported that applicants of other cosmetic surgeries were dissatisfied with their appearance.As a result, they suffered from affective disorders, anxiety, depression, low emotional health, poor quality of life, body image dissatisfaction, low self-esteem and loss of social support.Therefore, they underwent cosmetic surgery to relieve from these problems (23,24).Calogero et al (2010) considered body shame as the cause of women's desire for cosmetic surgeries (25).Henderson et al (2005) also found that the increasing acceptance of cosmetic surgery is the reduced satisfaction with physical appearance, fear of being unattractive and age (26).
Zwier (2014) reported concerns of women about their appearance as their main motive for labiaplasty (27).Swami et al (2009) showed that people who know themselves less physically attractive are more likely to do cosmetic surgery (10).Farnham et al (2012) found that low self-esteem, life dissatisfaction and feeling of low attractiveness are the greatest motivations of people to perform cosmetic surgery.People with extremely low self-esteem may suffer from depression (8).Through a qualitative study, Reardon et al (2016) reported low self-esteem as women's reason for cosmetic breast surgery (13).
Escape from loneliness is another main category emerged from data.Escape from loneliness involves three subcategories" Feeling of inner void", "feeling of a lack of love in life" and "lack of misery business".Many participants stated that Feeling of inner void, lack of love in lives and lack of misery business lead people to find solutions for escape from these problems; So the first way that came to their minds was that change their face to perhaps be a change in their work and life.Therefore, cosmetic surgery is one of the measures considered to possess something missed in everyday life; a way to fill inner emotional void in life.In this regard, no study was found on Escape from loneliness as a reason for decision to undergo cosmetic surgery.However, several studies showed that loneliness causes problems in people's lives.Stickley et al (2016) suggest that loneliness is a global and normative phenomenon; chronic loneliness is associated with negative emotions.Loneliness also can cause severe and painful sadness and can even be life-threatening (28).
Stickley et al (2013) concluded that loneliness is associated with lower health and risky health behaviors such as smoking, alcohol consumption and bad points to oneself physically (29).
Heinrich and Gullone (2006) argue that feeling of loneliness influences social interactions, way of life and mental and physical health of people through feeling of emptiness and sadness.Feeling of loneliness is associated with psychosocialsocial problems such as low self-esteem and low sense of competence, mental disorders such as anxiety and depression; in addition to inability to establish a decent life, this leads to frustration and emptiness (30).
Fear of the unseen is a main category extracted from the study.Fear of the unseen involves two sub-categories "fear of losing attention "and "fear of being compared".Among married women, spouses play an amplifying role along with other personal motives for cosmetic surgery.In this regard, the results are relatively consistent with some other studies.Through an ethnographic study of Brazilian women, Edmonds (2002) found that fear of being replaced by a more attractive woman is the main reason of married women for cosmetic surgery (31).Reddy (2013) in his qualitative study says, when the confirmed appearance by others creates an incentive to improve his appearance (32).Frederick et al (2007) reported that older women might experience more pressure to perform surgery, because they feel that they are competing with young women for their partner's attention (33).
Nerini et al (2014) concluded that although being compared is considered as a motivation for perform cosmetic surgery, but this is not a significant mediator (34).Menzel et al (2011) also stated that being compared which could be a motivation for cosmetic surgery has been ignored (35).This finding is inconsistent with the current study.

CONCLUSION
Three main categories (feeling of inferiority, Escape from loneliness and Fear of the unseen) derived from experiences of participants indicate that they are faced with feeling of inferiority and tend to undergo face cosmetic surgery to Escape from loneliness and fear of the unseen regardless of complications of these surgeries.It seems that they like to get rid of a set of problems, difficulties, mental conflicts and concerns.
It seems that cosmetic surgery has been introduced as a consumer product rather than a serious medical intervention.This may cause adverse consequences.However, if nurses know what the patient wants, why he wants it and how he has decided to do surgery, risks of cosmetic surgery is likely to be reduced.Moreover, awareness of reasons for doing cosmetic surgery will help to some extent to reduce social damages.Health care providers, particularly nurses, by having community based views can make efforts to change positive attitudes of people and improve psychological insecurities through cooperation of families and educational interventions.
In this study, it was tried to include diverse people.However, other people may have experiences other than what was presented in this study.Hence, it is recommended to repeat this study in other cities.This study was conducted among those who had undergone face cosmetic surgery, while other cosmetic surgeries are also common in Iran.Thus, experiences of people who undergo other cosmetic surgeries remain unknown.Future studies should identify more factors which may predict interest of people to do cosmetic surgery.

Table 1 :
Personal Characteristics of the Participants