Causes and challenges of males’ rhinoplasty in Iranian population: Qualitative study

Background: Rhinoplasty is a cosmetic surgery for which the society and the individual incur heavy costs. The present study is an attempt to elaborate on the causes and challenges of males’ rhinoplasty in Iranian population. Methods: The study was carried out as a qualitative study using content analysis method. Totally, 20 participants (16 clients, one family member, and three care-givers) were selected purposefully and participated in semi-structured and in-depth interviews. With 20 interviews, data saturation was achieved. Data analysis process was conducted manually along with the interviews following Lundman and Graneheim method. Results: Data analysis revealed 614 primary codes and the continuous examination and removal or repetitious codes left 417 codes, nine sub-themes, and two themes namely the reasons for rhinoplasty (lack of condence, hope for a better face, seeking attention, keeping up with the Joneses, and persuasion by others) and challenges (family challenge, social atmosphere, nancial problems, and unwanted consequence). Conclusion: The lack of condence and the hope of having a more beautiful face were the motivators. Family challenges, nancial problem and the side effects the were in way of men for


Background
Social changes of the modern world have increased the emphasis on physical appearance and concerns about physical appearance in individuals. As a result, cosmetic surgeries rate has increased recently (1).
Rhinoplasty is a cosmetic surgery to alter the internal and external form of the nose (2). It is one of the most challenging operations among other plastic surgeries. Despite the complicacies, it is the second common cosmetic surgery (3). This can be explained by the fact that the nose is at the center of face and has a critical effect on appearance. So that it draws more attention if there is a slightest problem in its form (4). Rhinoplasty is the fth top cosmetic surgery in the world (5), so that 850 thousand rhinoplasty operations were performed in the world in 2014 (3). Over the past few decades, a surge in cosmetic surgery has taken place in Iran so that Iran is among the top 10 countries in terms of cosmetic surgeries (6). In 2012, Iran was at the top of list of countries in terms of popularity of cosmetic surgeries. Iranian men spend more than US$50 million on rhinoplasty every year (7).
Although, rhinoplasty can improve all aspects of quality of life, attenuate depression, and increase selfesteem (8), it also causes many risks and not all expectations of the patient and physician are always met. For instance, rhinoplasty may cause respiratory problems, which is reported by 70% of the patients (9). Each of the side effects of rhinoplasty can have a profound effect on the outcome in terms of beauty and performance not to mention the nancial load on the family and society (10).
Studies have shown that the desire to become more beautiful (4) and negative mental image of the body (11) are the main incentives for cosmetic surgeries and rhinoplasty in particular. Aging, increase in social interactions, exposure to the media and peers' feedbacks affect one's attitudes to rhinoplasty directly and indirectly (12). In addition, self-con dence, self-e cacy, and wrong self-perception affect one's decision about cosmetic surgery. Such surgery might have a positive effect on self-esteem and self-e cacy (13). Studies have reported social acceptance and con rmation, wining public attention and the opposite gender's attention in particular, and better job opportunity and condition as the main determining factors of cosmetic surgeries (7). Some studies have reported that mental health and self-image have no relationship with the decision to have rhinoplasty (14).
Studies have con rmed a decrease in the quality of life after plastic surgery, which is mostly due unnecessary surgeries, medical errors, and damages to the nose function. A decline in social support due to the unacceptable outcomes of rhinoplasty mostly in terms of appearance, family and peers' reactions, and performance problems of the upper respiratory system all can have negative effects on the quality of life of individuals (15).
Today, cosmetic surgeries are growingly become popular among men and this can be a risk to their physical and mental health not to mentioned the nancial load on the individual, family, and society [7]. Therefore, it is imperative to uncover the causes of doing such surgeries (4,16). Through shedding light on the causes and challenges of rhinoplasty in men, which is a step to enrich the literature, better programs and rational approaches for managing the issues can be developed. The present study is an attempt to elaborate on the causes and challenges of rhinoplasty in Iranian men following a qualitative approach.

Design:
The study was carried out as a qualitative research using by content analysis method (17) in rhinoplasty clinics located in Kermanshah and Shiraz-Iran. The Study was conducted from March 2019 to January 2020.

Participants:
The participants were individuals who had the rhinoplasty surgery. To observe the highest diversity of sampling (18), close family members and rhinoplasty surgeons and nurses in rhinoplasty operation room were selected as participants. Inclusion criteria included at least one week passed from the surgery (to ensure that physical ability to participate in the interview is regained), at most six months passed from the surgery (to avoid reminiscence bias) and desire to participate in study.

Data gathering:
The main way of data gathering was in-depth semi-structured interviews. If needed, eld notes were also collected. The main interviews were face-to-face on different occasions (morning and afternoon) at the clinics or other places to the convenience of participants. The interviewer ( rst author) was quite familiar with local accents in Kermanshah and Shiraz. All the interviews were voice recoded with permission of the participants. Depending on the participants' energy, the interviews took between 50 and 70 min. Data gathering process continued until data saturation, which was the 20th interview. To facilitate data gathering, guide questions were used in the interviews.
1. How did you conclude that you needed a nose job? 2. How did you bring the idea of cosmetic surgery? Data analysis was based on Granheim and Lundman's ve-step method (19). After each interview, the recorded audio le is listened for several times and then transcribed using MS-Word 2010. To gain a general image of the interview content, the whole text is read and semantic units and primary codes are extracted (the sentences were broken into semantic units). Afterwards, the similar primary codes were categorized in general categories and the main themes were extracted eventually.

Rigor:
To ensure data vigor, the four criteria of creditability, con rmability, dependability, and transferability were used (Guba and Lincoln 1985) [17]. The author kept his connection with the research environments, interacted with the participants through telephone, and won their trust. This also enabled the author to familiarize himself with the research environment. Sampling covered a wide range of clients, close relatives, and therapists in terms of age, gender, and work experience, which added to the creditability of the data. The text of some of the interviews and the results of analysis were provided to experts of qualitative research for revision. In addition, the participants received the ndings and analysis report for con rmation (member check). A deep description of the participants' experiences was also provided along with direct quotes from the participants Results Totally, 20 interviews were performed with 16 care-seekers, three therapists, and one family member. Table 2 lists the demographics of participants.  One of the sub-themes found in the study was lack of con dence which was comprised of codes namely low con dence, distorted mental image, obsessive attention to appearance, being mocked by friends and peers, in uenced by negative feedbacks of others, negative effects of appearance, depression, and assuming one's appearance as a weakness or a problem in social interactions and relationships.
Some of the participants were in uenced by the negative feedbacks on their appearance by others. There were cases of being mocked by others and obsessive attention to physical appearance. The negative effects of these led to disorder in mental image of oneself so that they would see their nose as a disadvantage and lose their con dence. The decline in self-con dence creates disorders in social relationships. In this regard, the participants stated: "It only takes a dozen of negative feedbacks to lose your con dence and then you think you have to do the surgery…" (No.11). "I would watch myself in mirror and there was nothing wrong with the nose. But, my friends' comments in uenced me…" (No.15). "If there were a few classy individuals in a party, I would not dare to go…" (No.9). "I can't say that I was depressed, but I was not interested in going out and being seen by others…" (No. 16). "People only see the nose and don't care about what you have to say…" (No.1). "Seeing myself in mirror was bothering…" (No.11).
Some of the participants had a different experience. Despite the positive opinions of the friends about their nose, they had a negative mental image of themselves and consequently found themselves in a lower status. "Everyone would say that my nose is OK, but I had a problem with it, I thought it was too bid…" (No.2). "Although, everyone would say that your nose ts you face, I liked to have nose job anyway…" (No.4). "You always think that your face is uglier than others' and this affects your con dence…" (No.14). A cosmetic surgeon noted: "These individuals suffer body dysmorphic disorder. Most of them do. An individual, who does not like their face, is not healthy." In some cases, the mental engagement and the negative effect of ones' physical appearance on spirit is too high that people develop depression. A participants noted: "appearance change through nose job solves depression…" (No.12). A nurse in rhinoplasty operation room said: "Many of the patients suffer depression and physicians recommend nose job as a way to change." The clients underwent rhinoplasty to have a better face and solve their lack of con dence.

Hope for a better face
Another sub-theme was the hope for a better face including the codes namely desire to become more beautiful, having better feedbacks on one's photos, and having a different physical appearance. All the participants decided to have a nose job in the hope for a better face and because of the importance of physical appearance. In this regard, some of the participants stated: "I was only thinking about physical beauty…" (No.1). "Like women, men also need to be beautiful…" (No3). "I wanted to be beautiful…" (No.2).
Some of the participants had a distorted mental image of their appearance so that they could not stand their photos and to have a better appearance in photos, decided to have a nose job. A participant noted: "One thing that bothered me most was the septal division in photos…" (No.6). A cosmetic surgeon said: "Many do nose job for their wedding ceremonies and the photos…." Some of the participants highlighted dissatisfaction with physical appearance and the desire to alter their physical appearance. "Some like a different face…" (No.14). "I wanted change and difference…" (No.16).

Seeking attention
The next sub-theme extracted from the interviews was seeking attention. The codes under this sub-theme were drawing attention, drawing attention of the opposite sex, and the belief in the effect of rhinoplasty on having a better marriage opportunity. Some of the participants underwent the surgery to receive more attention and to receive more love. Given the expected increase in facial beauty, the participants believed that after the surgery, they can enjoy more attention and more friends. In this regard, some of the participants reported: "You can attract more people after a nose job…" (No.2). "With more beauty, you can expect more friends and attention…" (No11). "They pay you more attention when you have a nose job…" (No.16).
Some of the participants believed that one's appearance is a factor in marriage opportunity and that the face is very important for marriage. Therefore, they decided to have a nose job to attract the opposite sex. "Nose job is very important for marriage…" (No.6). "I would try to cover my nose by my hand or keep my head down when I was hanging out with girls…" (No.12). The participants underwent nose job in the hope for a better face and attract more people.

Keeping up with the Joneses
This sub-theme consisted for codes viz. keeping up with fashion and defeating rivals. Through their social interactions, people might be affected by the fashion trends. Increase in the popularity of nose surgery among men can affect the decision for rhinoplasty. In this regard, some of the participants reported: "Well, it's now a norm in the society and as a member of the society I can see that everyone is having a nose job…" (No.5). "One reason for me was that having a nose job was the fad" (No.15).
Some of the participants decided to do nose job only for keeping up with the Joneses and defeating rivals. A participant noted: "One reason for me was to keep up with the Joneses…" (No.8). A nurse in rhinoplasty ward with extensive experience in this eld mentioned: "90% of nose jobs are unnecessary, still, people want to keep up with the Joneses." She also commented, "It's more about keeping up with the Joneses, in some cases, all members of a family do rhinoplasty." Some of the clients expected a better face and through this, defeating their rivals.

Persuasion by others
Persuasion by others consisted of motivation by others and friends, positive effects of others' experience, and the effects of mass media. Some of the participants underwent rhinoplasty based their friends, family members, and relatives' recommendations. "My friends highly recommended it. They would say that you can change your face…" (No. 19). "My friends were a great reason for my decision…" (No.6). "It was my uncle's nose job…" (No.8).
Some were motivated by seeing satisfaction in others after rhinoplasty and accept their recommendation in the hope of having a better face. "My friend had an ugly face, but after the surgery he was a different person…" (No.5). "Seeing how my friends' faces were changed convinced me to have a nose job…" (No.16).
Some of the participants followed changes in appearance of others after rhinoplasty in social media and found them reason enough to do rhinoplasty. "I visited personal page of physicians on Instagram and saw how people had been changed. This made me more serious about the decision…" (No.14).

Challenges Family challenges
Family challenges was one of the sub-themes in making decision about rhinoplasty with two codes of negative reaction of family members and cultural-religious prejudice, which were among the main challenges in making decision for rhinoplasty. Some of the clients had decided not to do rhinoplasty due to family and parents disapprove of the surgery in particular. The majority of participants noted the belief that rhinoplasty is for women as the main reason for the disapproval by the family. In this regard, some of the participants reported: "I changed my mind for several times, my family didn't approve of rhinoplasty…" (No8). "At rst, my family didn't accept the idea of nose job by men…" (No.11). "My father disapproved of nose job by my brother, saying that he wants to be like girls…" (No.14).
Some of the participants highlighted religious-cultural prejudices as the obstacles in the way of rhinoplasty. Some societies and families do not accept the idea of cosmetic surgeries by men and some families nd it as intervention in God's job. These are the obstacles of rhinoplasty. "My mother used to say that this is like intervention in God's job…" (No.16).

Social atmosphere
Social atmosphere was another sub-theme found through data analysis consisting of the codes concerns about negative reactions by others and the belief that it is a women's thing. Some societies do not accept rhinoplasty by men and believe that it is for women. Some of the participants had thought about leaving the idea of rhinoplasty due to their concerns of negative reactions by others. "The society is not quite OK with cosmetic surgery by men. They might say that he is a sissy and he is like girls…." (No.3). "Some would express their negative attitudes towards rhetorically and make you feel that this is for girls…" (No.15). "I myself was not OK with it and didn't like to do the surgery during the university. You know, some may say that you are a sissy and this bothers me. I didn't want anyone in the university know that I have had a nose job…" (No.6). A family member said, "He's not OK with it. He feels shy being seen among relatives."

Financial problems
Another sub-theme extracted from the interviews was nancial problems with two codes of nancial limitations and medical insurance coverage. Many of the care-seekers give up rhinoplasty due to the high expenses and that medical insurances do not cover it. Some, however, underwent the surgery despite the expenses. A participant said: "Some might even sell their smartphone to pay for the surgery" (No.4). "Some long for cosmetic surgery, but they don't have the money…" (No.1).
Unwanted side-effects of surgery

Discussion
The causes and challenges of rhinoplasty in Iranian men were elaborated following a qualitative approach. Lack of con dence was one of the main causes of rhinoplasty in men. In fact, excessive concern about physical appearance, being mocked by others, and the effects of negative feedbacks by others distort one's mental image of himself. The problem with mental image of oneself was too high in some of the participants that they could not stand their own pictures. These factors created a desire for diversity and having a more beautiful face. These individuals would do cosmetic surgery in the hope of beauty.
Therefore, there is a relationship between problems with mental image of oneself and self-con dence. People tend to have a low self-con dence when their mental image of themselves is not good (20). A decrease in self-con dence and problem with mental image of oneself affects social interactions in a negative way (21). People might seek others' attention due to low self-con dence and negative mental image of oneself (12). Studies have supported the effect of low self-con dence and negative mental image of oneself on the desire to cosmetic surgery (22,23). Ahmadpanah et al. showed that body dysmorphic disorders and social/cultural attitudes to ones' appearance are connected to each other in Iranian teenagers. They added that self-con dence affects this disorder, while other factors like social feedbacks, concerns about having a chance to marry, and success at work had stronger effects on satisfaction with one's appearance of physical form (24). Yin et al. argued that negative self-assessment resulted in decision to have rhinoplasty surgery (13).
Seeking attention was another reason for men to do rhinoplasty. Some of the care-seekers had obsessive attention to their appearance and because of the belief that rhinoplasty brings better chances for marriage; they would undergo cosmetic surgery to grab the attention of opposite sex. It was argued in (7) that wining the attention of the opposite sex was a key factor in rhinoplasty.
The results showed that being motivated by others, the media, keeping up with the Joneses, and seeing the results of surgeries with others were the factors in deciding to have rhinoplasty. These ndings are supported by other studies. Arab and Walker highlighted the effect of media on public tendency to cosmetic surgery (25,26).
The results showed that men have to face family challenges, social atmosphere, nancial problems, and fear of the outcomes of surgery in their way of having the surgery. Cosmetic surgery in Iran is generally seen as a womanly action and men have to deal with others' negative feedbacks if they do cosmetic surgery. They might be even deserted by their families (7). Another challenge was the belief of inconsistency between cosmetic surgery and religious codes. Some families in Iran think that intentional change in one's face is like intervention in God's work.
Financial problem was another challenge for Iranian men who want having rhinoplasty. Cosmetic surgeries are expensive in Iran (7) and there is no medical insurance coverage for them. The fear of the unwanted side-effects of the surgery was another challenge. Some of the participants were concerned about probable problems at work or losing their jobs. Some were concerned about having an unsuccessful operation and the problems afterwards. Still, these challenges had not stopped the participants as all of them had a rhinoplasty operation.
This study is the rst work on the causes and challenges of rhinoplasty in Iranian men from their own perspectives. The results can be useful for the social and health programmers to prevent probable damages. The study was not free of limitation. The majority of the participants were reluctant to give their permissions for voice recording the interviews. Only after brie ng about the study and that the recorded interviews and the personal information of the participants will remain con dential, they gave their consent.

Conclusion
The study showed that the lack of con dence, the hope of having a more beautiful face, seeking attention, keeping up with the Joneses, and persuasion by others were the motivating factors. In addition, family problems, social atmosphere, nancial problem, negative side effects of the surgery were challenges in the way of men for having rhinoplasty. The planners can use the results in the health system to control the motivations and the demand for rhinoplasty.

Consent for publication
Not applicable.