Interest in Rhinoplasty and Awareness of Postoperative Complications Among Female High School Students in Riyadh, Saudi Arabia

Background Rhinoplasty and revision rhinoplasty are facial cosmetic operations that have potentially profound psychological implications for an individual.In recent years, rhinoplasty has increased internationally because of body dysmorphic disorders but also social media influence. As with any surgery, rhinoplasty carries risks, and the aim of this study was to explore female high school students' interest in rhinoplasty and their awareness about its postoperative complications in Riyadh, Saudi Arabia. Methods We employed a cross-sectional design for the study, which included 413 female high school students aged 14 to 17 years. Participants signed a consent form, and data were collected through an online survey from September to November 2022. A validated questionnaire tested for reliability was used. The level of knowledge and interest in rhinoplasty was compared with the socio-demographic characteristics of the female students using the chi-squared test. A p-value of 0.05 was considered statistically significant. Results A total of 413 female high school students responded to our survey, and 135 completed questionnaires were received. Nearly half (48.7%) of the students were happy about the current form of their nose. Among the students, 74.3% would not consider undergoing rhinoplasty, and the most common reason was satisfaction with their nose (69.4%). Those who did intend to undergo rhinoplasty (25.7%) were primarily interested in improving their appearance (74.5%). The total mean knowledge score was 6.01 (SD 3.27) out of 12 points, with 61.7% classified as having poor knowledge levels, and the rest (38.3%) were considered as having good awareness. Conclusions In our perception, the number of teenagers wanting rhinoplasty is increasing. Questions about their knowledge level, attitude, and perspective regarding the procedure should be important considerations for the surgeon.


Introduction
The nose is a prominent feature of the face and is often considered a beauty landmark. Facial appearance is closely tied to the self-image, self-confidence, and self-worth of the individual. Derangements in nasal structure, whether from surgery, trauma, or natural causes, have numerous implications for the emotional well-being of the individual [1]. People who are dissatisfied with the appearance of their nose may opt to have cosmetic surgery called rhinoplasty to alter the shape or appearance of the nose while preserving or enhancing the nasal airway [2]. Rhinoplasty and revision rhinoplasty are facial cosmetic operations with profound cosmetic and psychological effects on the patient [1].
In recent years, the number of rhinoplasty operations has increased in Saudi Arabia and currently represents 30% of all cosmetic surgery procedures. This increase is in part coming from a desire to correct a dysmorphic facial feature, but the influence of beauty norms as portrayed on social media is playing a larger role in people's decisions [3]. It has been reported that considering a cosmetic procedure is greatly influenced by spending hours viewing cosmetic surgery-related material on social media together with the depiction of what are considered ideal features [4].
There are obvious risks involved in rhinoplasty, especially reduction rhinoplasty. Although severe complications are rare, there are many short-and long-term complications that could lead to aesthetic dissatisfaction, patient disappointment, and even functional problems [5]. Complications of rhinoplasty are grouped into two categories: aesthetic, which may require revision rhinoplasty, and non-aesthetic [6], such as breathing disturbances that are reported by 70% of all revision rhinoplasty patients. Also, damage to the skin and soft tissues can cause atrophy, fibrosis, numbness, and formation of cysts from displaced mucosa or subcutaneous granulomas. Infections are rare but can be life-threatening in the case of toxic shock syndrome. The risk is higher when sinus surgery and rhinoplasty are combined [7]. Awareness of the risk from complications should be part of an individual's rhinoplasty decision-making process.
Although the number of adolescents electing to have plastic surgery, especially rhinoplasty, is increasing, there has been little emphasis on complications and few articles in the world's literature have analyzed their beliefs and attitudes toward them. The aim of this study was to explore female high school students' interest in rhinoplasty and their awareness about its postoperative complications in Riyadh, Saudi Arabia.

Study design, area, and settings
A cross-sectional study design was conducted, as the study only focused on the population's interest and awareness over a specific period of time. The survey was distributed to female schools from different areas (North, South, East, and West) in Riyadh. In Saudi Arabia, education is organized into kindergarten, primary, and secondary units, and numerous institutions offer all three units in their schools. The Saudi System first has the primary stage then splits into intermediate and secondary stages. Intermediate students are 13 to 16 years old and secondary students are 17 to 19 years old [8]. The goal of the study was to assess the interest of female high school students in rhinoplasty and their awareness of its postoperative complications in Riyadh, Saudi Arabia.

Inclusion and exclusion criteria of study participants
Our study included 413 female high school students aged 14 to 17 years who responded to the survey. Males were excluded along with students younger than 14 or older than 17 years. The data were collected online from September to November 2022.

Data collection process
After signing the consent form, the participants' data were collected through an online survey distributed via social platforms to high school girls in all areas of Riyadh, Saudi Arabia. The questionnaire was developed by Aliasghar Arabi Mianroodi and Narges Khanjani [9]. Their permission was obtained to use the validated version in this study. It has three sections. The first section includes the subjects' demographics obtained by a series of five multiple-choice questions. Section 2 includes five multiple-choice questions about attitude toward rhinoplasty, and section 3 has 13 short-answer questions to gauge the students' familiarity with the postoperative complications of rhinoplasty.

Data analysis
The awareness of rhinoplasty complications was assessed using a 12-item questionnaire, where a "yes" answer was coded as 1 and "no" was coded as 0. The overall knowledge score was calculated by adding the scores on all 12 items (0-12). The higher the score, the greater the understanding of the complications of rhinoplasty. A score of 7 (60%) was used as the cutoff point to decide on the level of knowledge. Students were considered as having "poor" knowledge if the score was 7 points or below. Above 7 points was considered a "good" knowledge level.
The data for categorical variables were represented by numbers and percentages, while means and standard deviations were used for continuous variables. The level of knowledge and interest in rhinoplasty were compared with the socio-demographic characteristics of the female students by using the chi-squared test. A p-value of 0.05 or below was considered statistically significant. All data analyses were performed using the Statistical Packages for Software Sciences (SPSS) Version 26 (IBM Corp., Armonk, NY).
This study was approved by King Abdullah International Medical Research Center (IRB/1268/22).

Results
A total of 413 female high school students responded to our survey and 135 completed questionnaires were received; the rest of the questionnaires did not meet our inclusion criteria. Table 1 shows the socio-demographic characteristics of the students. The most prevalent average age was 17 years (48.9%). The majority of the students (77.5%) were born in Riyadh City, and those living in the eastern area constituted 37.8%. Regarding parents' education, most had a bachelor's degree or higher (father, 71.4%; mother, 66.1%). In addition, 21.1% of the students indicated that at least one of their relatives or friends had undergone rhinoplasty ( Table 1).   Table 2 illustrates the students' attitudes toward rhinoplasty and their knowledge about rhinoplasty complications. According to our results, nearly half (48.7%) of the students were happy about the current form of their nose. The proportion of students who were not interested in rhinoplasty was 74.3%, and the most common reason was satisfaction with their nose (69.4%). Those who intended to undergo rhinoplasty comprised 25.7% of the group and the most commonly given reason was to enhance beauty (74.5%). The most preferred quality of the doctor who would perform the operation was their work ethic (91.5%).
Regarding knowledge about rhinoplasty complications, students were aware that the most common complication of rhinoplasty was dissatisfaction with the new nose (70.5%), followed by headache (70.2%) and nose blockage (68%). The total mean knowledge score was 6.01 (SD 3.27) out of 12 points, with 61.7% classified as having poor knowledge levels and 38.3% considered as good (   Table 3 shows the relationship between the level of awareness and knowledge about rhinoplasty complications and students' attitudes and socio-demographic characteristics. The p-value was calculated using the chi-squared test. We found that the socio-demographic data and attitude toward rhinoplasty did not have a significant relationship with the level of knowledge (p>0.05) ( Table 3). When measuring the relationship between interest in rhinoplasty and socio-demographic variables ( Table 4), it was found that an interest in rhinoplasty was significantly more common among those students with relatives or friends who underwent rhinoplasty (p<0.001) and those who were unhappy with the current shape of their nose (p<0.001). Other socio-demographic characteristics of students did not significantly influence interest in rhinoplasty (p>0.05) ( Table 4).

Discussion
Our results showed that almost half of the participants were happy with the shape of their nose and were not contemplating surgery. However, more than half of the female high school students in Kerman, Iran, stated that they would like to undergo rhinoplasty [10]. This observation could be the result of a number of reasons, one of which is the diversity of cultures since this has a major effect on a child's education, beliefs, thoughts, and habits. Parental education was also stated as a mediating factor because, in some studies, as parental education increased, the rate of cosmetic surgery decreased [11]. This was in contrast to our study, which showed no relationship between the level of parental education and the surgery opt-in rate.
In our study, there were a number of reasons why participants chose not to consider rhinoplasty, with the most common being that they were happy with their nose as it was, followed by religious beliefs, fear of side effects, and financial cost. However, around 25% stated that their purpose in considering rhinoplasty was to enhance their beauty, which corroborates a similar study in Kerman, Iran [10]. However, in another study conducted in California, 30% of participants said that their choice was influenced by someone who had undergone the surgery [12]. This is mirrored in our study by the fact that the number of students who had an interest in rhinoplasty was significantly higher among those with relatives or friends who underwent the procedure.
Regarding the choice of a surgeon, the participants in this study who were considering rhinoplasty implied that they preferred to be operated on by an experienced cosmetic surgeon who had performed many successful operations. That was the primary factor that mattered most to them. In contrast, a study that was conducted in Yazd, Iran, concluded that the participants preferred to be operated on by someone with a pleasant personality who had lots of patients and did not charge as much as others [11].
Over half of our sample population had less than average knowledge about the possible postoperative complications of rhinoplastic surgery. Our students knew about the risk of dissatisfaction with the new nose, as well as the common consequences of headache and sinus blockage, but they did not consider more serious complications such as the need for reoperation or the possibility of death from infection. Another study in Iran showed that their population was more worried about the risk of reoperation and possibility that the new nose would not match the face [9].
A number of studies suggested that psychological disturbances or poor general mental health can urge people toward rhinoplasty [13,14]. In fact, a Norwegian study revealed that an interest in rhinoplasty was more likely in young women presenting with body dysmorphic disorder [15]. This was also supported by a study conducted at the Shiraz University of Medical Sciences in Iran [16]. Therefore, it would seem prudent to do some form of psychological assessment before the operation is scheduled. This subject is an important one, and further studies should be conducted in Saudi Arabia to assess the psychological aspects of an interest in rhinoplasty.
This study was limited in its generalizability because it only surveyed female high school students in Riyadh City, Saudi Arabia. Additional studies need to include both sexes and a greater range of ages.

Conclusions
In our perception, the number of teenagers wanting rhinoplasty is increasing internationally, assessing their knowledge and understanding of the procedure and their attitudes and perspectives about it should be an important part of the patient work-up for the surgeon performing the operation. Careful attention to the individual's reasons for desiring the surgery can contribute to a more successful surgical outcome, and an understanding of the potential risks and complications can provide greater satisfaction for the patient.