Ethnic Variations in Knowledge, Attitude and Perception towards Facial Plastic Surgery

Abstract

Background: Over the last few decades, there has been greater attention given to aesthetic beauty due to the influence of social media. Globally, cosmetic surgery has increased in popularity and has become more socially acceptable not only in the West, but also in Asian countries such as Korea and Japan. This study aims to explore the knowledge, attitude and perception of Singapore citizens and permanent residents regarding facial plastic surgery.

Methods: The participants completed a questionnaire survey and the responses to the items were analysed using SPSS. Singapore citizens and permanent residents between 21 and 70 years old who were attending the Otolaryngology Clinic in our institution and who had not undergone any facial plastic surgery or suffered from facial trauma previously were invited to participate in the survey.

Methods: This study found a statistically significant difference between the importance that Indian participants attributed to appearances compared to the other ethnicities (p<0.001). One hundred percent of Malay participants felt that facial plastic surgery is more acceptable in society today compared to 97.4% Chinese and 73.9% Indians (p<0.001). It also revealed that Chinese participants were less satisfied with their lips (p=0.044) compared to the other races.

Conclusion: Majority of Singaporean Citizens and Permanent Residents feel that Facial Plastic Surgery is socially acceptable now. This information can be helpful in planning service delivery in private clinics.

Introduction

Life expectancy has increased steadily over the last century and people are generally leading a healthier life than anytime in human history. Often patients perceive a mismatch between their physical well-being and their physical appearance [1]. With greater affluence and the influence of social media, aesthetic plastic surgery is gaining popularity globally in attempting to improve one’s self confidence, social mobility and quality of life [2, 3]. This survey aims to investigate whether this phenomenon has influenced Singaporean citizens and permanent residents.

Beauty can be greatly subjective. It was previously believed that the Caucasian appearance is the standard of beauty [4]. However, recent surveys have revealed that majority of non-Caucasians considering rhinoplasty do not desire Caucasian-type noses [5]. This could be due to changing trends, or it could be due to better understanding of establishing harmony with respect to an individual’s facial features and race in facial plastic surgery [6, 7]. Different cultural backgrounds may lead to varied attitudes towards the emphasis and definition of attractiveness [8, 9]. For example, the traditional Chinese cultural norm may associate one’s facial features with one’s destiny and luck [10]. As Singapore has a multicultural society, this project also aims to investigate the inter-ethnical differences that Singaporeans may possess in the perception of attractiveness and their attitudes towards facial plastic surgery.

Material and Methods

Inclusion criteria

Chinese, Malay or Indian patients or their carers attending the Otolaryngology, Head and Neck Clinic in Khoo Teck Puat Hospital, aged between 21 and 70 years old, were randomly selected for this cross-sectional survey. With their verbal consent, they were given a questionnaire to complete (See Appendix 1). They were categorized into 3 main categories according to their ethnicity (Chinese, Malay or Indian) for analysis. The responses of the different ethnic groups were compared regarding their attitudes towards facial plastic surgery in general and their perception of attractiveness regarding the various facial features (eyes, nose, lips). Responses were collated and analysed using the SPSS system. The responses for each question were collated and input into SPSS. Analysis was performed using Chi-square for multiple choice questions and Kruskal-Wallis for Likert scale questions. For ranking questions, multiple responses analysis was performed and the p-value was calculated using linear regression.

Exclusion Criteria

Those who had undergone any facial plastic surgery procedure or suffered previous facial trauma were excluded from the survey.

Participants
A total of 143 participants were selected randomly at the Khoo Teck Puat Otorhinolaryngology clinic and invited to participate. Participants were briefed regarding the aims and objectives of the study and surveyed. 11 participants with prior facial trauma or facial plastic surgery and 3 participants with missing information regarding their race were excluded from the study. An additional 3 participants were excluded as they were not Chinese, Indians or Malays. A total of 126 respondents – 80 Chinese, 23 Indians and 23 Malays, was included in this study [Table 1]. The number of Male (62) and Female (52) participants [Table 2] was almost evenly split. Participants were also stratified by educational level and housing. There were 34.1% diploma holders, 1.6% PSLE (Primary School Leaving Examination), 18.3% O Level, 11.1% A level, 19.8% Degree, 4.0% Masters responders [Table 3]. Housing was used as a surrogate marker for income bracket in this study where participants staying in the 1-2 Room HDB (Housing Development Board) and 3-4 Room HDB groups were regarded as the lower income group, 5-Room HDB as middle income group and private housing such as condominium, executive mansionettes, bungalow, terrace, semi-detached houses were regarded as higher income groups. Most participants (40.5%) stayed in 3-4 Room HDB (Housing Development Board) flats compared to 5.6% in 1-2 Room HDB, 29.4% in 5 Room HDB, 14.3% in condominium/executive mansionette and 7.9% in bungalow/ terrace/ semi-detached houses [Tables 4].

Results

83.3% of all participants were aware of facial plastic surgery. 85.0% of Chinese, 73.9% of Indians s and 87.0% of Malay answered “Yes” to being aware of Facial plastic surgery [Table 5].

Overall

Chinese (45.6%) and Malay participants (47.1%) felt that the internet was the greatest influence regarding aesthetic surgery while Indian participants (36.8%) felt that television and radio was the greatest influence [Table 6]. However, this was not statistically significant. All Malay (100%) participants surveyed felt that aesthetic surgery is more accepted in society today compared to only 97.4% of Chinese and 73.9% of Indians [Table 7]. This was statistically significant (p <0.001).

Most participants (63.8% Chinese, 47.8% Indians, 56.5% Malays) did not personally know anyone who has undergone aesthetic surgery.

Using the Kruskal-Wallis test, there was a statistically significant difference (p<0.001) in how important the different races think appearance plays a part in one’s self-confidence. The mean score for Chinese was 3.64, Indian 4.43 and Malay 3.65 [Table 8]. The effect size calculated (Chi-square value / [N-1]) was 12.6%, which suggests that 12.6% of the variability in rank score is accounted for by race. Kruskal-Wallis test was repeated to compare between different ethnicities, such as Chinese and Indians, Chinese and Malays and lastly, Malays and Indians. There was a statistical significance between Chinese and Indians (p<0.001). There was also a difference between Malays and Indians (p=0.016) but no statistically significant difference between Chinese and Malays (p=0.691).

This statistically significant difference was replicated when participants were asked how beneficial they think aesthetic surgery is towards boosting their self-confidence (p=0.027) [Table 9]. However, this was the only statistically significant difference when comparing Chinese and Indians (p=0.008). It was not statistically significant when comparing Indians and Malays (p = 0.051) or Chinese and Malays (p=0.864).

All races felt that appearance was important to gain employment/work privileges, with a mean score of 3.46 for Chinese, 3.91 for Indian and 3.43 for Malay. There was no statistically significant difference between the races (p=0.069). There was also no statistically significant difference between the races regarding how important they think appearance plays a part in social interaction (p = 0.062).

Most participants (83.8% Chinese, 87% Indians, 87% Malays) did not consider undergoing aesthetic surgery. When given a choice, the most common reason amongst all the 3 races (76.9% Chinese, 50% Indians and 75% Malays) for undergoing aesthetic surgery was to boost their confidence. However, there was a statistically significant difference for the reasons against undergoing aesthetic surgery (p=0.032) [Table 10]. The majority of each race (62.5% of Chinese, 55.6% of Indians and 53.3% of Malays) felt that they were satisfied with their personal appearance and would therefore not undergo aesthetic surgery. Further analysis was performed to evaluate the statistically significant difference attained. The chi-square test was repeated comparing 2 races each time; this revealed a statistically significant difference (p=0.029) when comparing Malays and Chinese. This is likely due to the Chinese ranking fear of potential risks to health as the second most common reason (20.0%) for not undergoing aesthetic surgery compared to 0.0% in the Malay participants. Instead, the second most common reason for Malay participants was tied between aesthetic surgery being against religious beliefs (20.0%) and cost (20.0%). 10.0% Chinese cited cost as a factor and 0.0% cited aesthetic surgery being against religious beliefs as a factor against aesthetic surgery.

When asked to rank the most compelling reason to undergo and against undergoing aesthetic surgery, there was no statistically significant difference between the different races.

Facial plastic surgery

There was no statistically significant difference between the races on how satisfied they were with their facial appearance (p=0.088) with a mean score of 3.51 for Chinese, 3.82 for Indians and 3.62 for Malays participants. There was also no statistically significant difference between the races when asked to rank a feature of their appearance they would change first if given the option to or when ranking a feature in order of importance for attractiveness.

Lips

There was a statistically significant difference amongst the races when asked to score their satisfaction regarding their lips on a scale of 1 to 5 with 5 being the most satisfied (p=0.044). The mean score for Chinese was 3.60, Indian 3.86 and Malay 4.05 [Table 11]. Further analysis revealed that this difference remained statistically significant when comparing Chinese against Malay (p=0.047) but not when comparing Chinese with Indian (p=0.054) or Indian with Malay (p=0.990). However, when asked which aspect of their lips they would change first, there was no statistically significant difference in choice between the different races (p=0.573).

Forehead/ eyebrow/ mid-face/ ears

There was no statistically significant difference on the satisfaction score with their forehead (p=0.211), mid face (p=0.263), ears (p=0.338), eyes (p=0.291), nose (0.203), chin (p=0.269) or jaw (p=0.854). There was also no statistically significant difference when participants were asked to rank a feature of their appearance they would change first.

For the forehead, Chinese (20.0%) and Malays (35.0%) would change their prominent forehead while Indians (36.8%) would change the thinning of their hair first (p=0.421). In the mid-face, all three races (29.7% Chinese, 29.4% Indians and 36.8% Malays) would correct their flat cheek bones of the mid-face first (p=0.618).

Chinese (38.7%) and Malays (27.8%) would change the symmetry of their ears but Indians (29.4%) would change the shape of their ears first (p=0.953).

All three races (27.9% Chinese, 38.9% Indians 50% Malays) would correct their eye bags first (p=0.321). Additionally, all three races (25% Chinese, 16.7% Indians and 21.1% Malays) would change the shape of their nose first (p=0.943).

Chinese (45.6%) would lengthen their chin first. However, Indians (27.8%) would correct their retruded chin while Malays (44.4%)
would correct their protruding chin first (p=0.714).

Regarding the jaw, Chinese (40.6%) would choose to remove their excess fat while Indians (33.3%) would opt to remove the sagging skin and Malays (40%) would like to enhance their jaw line (p=0.434) first.

Education and Housing

There was no statistically significant difference when the analysis was repeated with participants stratified according to education level.

When data was analysed by housing, a higher percentage of participants who stay in 1-2 Room HDB have considered aesthetic surgery (42.9%) compared to other strata (15.7% in 3-4 Room HDB, 16.7% in Condominium/ Executive Mansionette, 20% in Bungalow/ Terrace/ Semi-D). This is in comparison to only 5.4% of participants staying in 5 Room HDB have considered plastic surgery. However, this finding was not statistically significant (p=0.120). There was also no statistically significant difference among the strata in grading their satisfaction with facial appearance on a scale of 1 to 5, 5 being most satisfied (p=0.557). The mean cores were similar across the strata with a mean score of 3.71 in 1-2 Room HDB, 3.67 in 3-4 Room HDB, 3.46 in 5 Room HDB, 3.61 in condominium/ executive mansionette and 3.78 in Bungalow/ Terrace/ Semi-D.

The only statistically significant difference was found in the number of people whom participants personally know to have undergone aesthetic surgery (p=0.043). This is likely attributed to participants staying in 1-2 Room HDB knowing a significantly higher mean of 3.00 people who have undergone aesthetic surgery while participants staying in 5 Room HDB knew a lower mean of 1.51 people [Table 12]. This remained statistically significant when comparing individual groups 1-2 Room HDB (p=0.046) and 5 Room HDB (p=0.047) against the others but not when comparing 3-4 Room HDB (p=0.138), condominium/ executive mansionette (p=0.137) and bungalow/ terrace/ semi-detached houses (p=0.903).

Discussion

The general Singaporean population appear to be aware of facial plastic surgery, largely influenced by social media (the internet, television and radio). This suggests that advertisement through social media is useful in spreading awareness of facial plastic surgery.

Based on our questionnaire results, most participants were satisfied with their appearances and did not consider undergoing facial plastic surgery. However, Indians appear to value appearance more significantly compared to Chinese or Malays in boosting one’s selfconfidence. A paper in India stated that physical appearance has been found to be an important determinant of an individual’s social status [10]. While one’s appearance did not result in perceived benefits inemp loyment or social interaction, it would be interesting to find out the reason behind the increased emphasis given to appearance in the Indian participants compared to the Chinese or Malay participants, and whether this is related to perceived difference in social status.

One reason that could possibly affect the different participants’ views would be religious beliefs. This is evident in Malays citing religious reasons as the second most compelling factor against undergoing facial plastic surgery compared to the Chinese who did not cite religious reasons as a factor. However, it is interesting to note that 100% of Malay responders felt that facial plastic surgery is more accepted in society today compared to 97.4% Chinese and 73.9% Indians. This could reflect a changing trend towards facial plastic surgery that is more prevalent in the Malay community compared to the Chinese or Indian communities [11]. Nevertheless, the findings of this study highlight the need to be racially sensitive when offering aesthetic surgery services.

The general perceptions of all 3 races appear to be largely similar in terms of ranking each facial feature and the most important factorfor each facial feature. This concurred with a previous study performed in an Asian community where ethnicity was a non-significantpredictor in the judgment of an attractive male or female profile [12]. The only statistically significant difference found in our survey was when participants were asked to rank their satisfaction regardingtheir lips. Chinese appear to be less satisfied with their lips compared to Malay or Indian participants. Other research studies have also reported an increasing trend of people in China, Japan and South Korea who have contemplated lip aesthetic surgery, where a short philtrum and an upturned vermilion is considered appealing to an Asian face [13]. This may be a helpful feature for aesthetic plastic surgeons to address in Chinese patients who are less forthcoming with their dissatisfaction of their facial features.

Housing was used as a surrogate marker of income bracket for the study. Interestingly, the lower-income group (1-2 Room HDB) knew a significantly higher mean number of participants who have undergone aesthetic surgery while the middle-income group (5 Room HDB) knew a significantly lower mean number ofparticipants. This correlated with the highest proportion of participants who have considered aesthetic surgery derived from the lower-income group and the lowest proportion of participants who have considered aesthetic surgery derived from the middle-income group although this did not reach statistically significant difference. A possible explanation could be that participants who are keen in aesthetic surgery would actively seek information regarding aesthetic surgery, which could lead them to have contact with individuals who have undergone aesthetic surgery.

This study compared the attitudes of the 3 major races in Singapore, namely the Chinese, Malays and Indians. Including the 4th major race in Singapore, Eurasians, could perhaps project a better representation of the Singaporean population. Additionally, it can be argued that this study showed a larger participation from the Chinese population compared to the other races, which is in fact representative of the proportion of Chinese in the Singapore population. An increased number of participants could be considered for future studies which would better reflect the Singapore population distribution.

Conclusion

This study concludes that the Indian participants attribute a greater emphasis on appearances compared to the other races. It also highlights the possibility of Malays being more receptive to facial plastic surgery in society today. Additionally, the Chinese participants appear to have less satisfaction with their lips compared to the other races.

This study also revealed that the 3 major races in Singapore are generally aware of facial plastic surgery but are satisfied with their appearance. This may be due to the population being sampled in this survey. Khoo Teck Puat Hospital generally serves the heartlands area of Singapore and the population in this region is not as affluent and may not have the same social pressures to undergo facial plastic surgery relative to the more affluent population in other parts of Singapore. Given more time and resources, further research studies could be performed to investigate the reason for the differences found.

References

1. Abel-Jan Tasman. Rhinoplasty – Indications and techniques. “GMS Current Topics Otorhinolaryngol Head Neck Surg.2007; 6: Doc09. [Crossref]
2. Davis RE. Rhinoplasty and concepts of facial beauty. Facial Plast Surg. 2006; 22: 198-203. [Crossref]
3. NolsteTrenite GJ. Considerations in ethnic rhinolasty. Facial Plast Surg. 2003; 19:2 39-245. [Crossref]
4. Romo T 3rd, Abraham MT. The Ethnic Nose. Facial plast Surg. 2003; 19: 269-278. [Crossref]
5. Yellin SA. Aesthetics for the next millennium. Facial Plast Surg 1997; 13:231-239. [Crossref]
6. Alain Tauka, NaylaBassil-Nassifb, Carole Mouhanna-Fattalb, Joseph Bouserhalb. The importance of using the entire face to assess facial profile attractiveness. Int Orthod.2016; 14: 65-79. [Crossref]
7. Sturm-O’Brien AK, Brissett AE and Brissett AE. Ethnic trends in facial plastic surgery. Facial Plast Surg. 2010;26:69-74.
8. Leong SC, White PS. A comparison of aesthetic proportions between the Oriental and Caucasian nose. Clin Otolaryngol Allied Sci. 2004; 29:672-676.
9. KhudeidaJ.The Art of Mian Xiang and Al Ferasah for Human Resources in Defensive Times. J Def Manag. 2013; S3:004. [Crossref]
10. Majethia AP, Vadgaonkar VD, Deshpande KJ, Gangurde PV. Perception of Aesthetics by Different Professionals of Different Communities. J ClinDiagn Res. 2015; 9: ZC18–ZC22. [Crossref]
11. Bishara S. Atiyeh, Mohamed KadryShady N, HayekRamziS and Musharafieh. Aesthetic Surgery and Religion: Islamic Law Perspective. Aesthetic Plast Surg. 2008; 32: 1-10. [Crossref]
12. Soh J, Chew MT, Wong HB. An Asian community’s perspective on facial profile attractiveness.Community Dent Oral Epidemiol. 2007; 35:18-24. [Crossref]
13. Bai-lin Pan. Upper lip lift with a “T”- shaped resection of the orbicularis oris muscle for Asian perioral rejuvenation: A report of 84 patients. J Plast Reconstr Aesthet Surg. 2016; S1748-6815: 30232-30237. 2009; 25-26.