Caspian Journal of

1. Introduction
Physical attractiveness has become a topic in modern times that has established new standards and plays a significant role in shaping people’s relationships. Cosmetic surgery is a product of the advancement of medical knowledge, responding to the improvement of living standards, and adapting to the new demands of contemporary society. It has a psychological impact on the formation of current societal norms [1]. Currently, the increase in medical errors has raised public concern among health policymakers. In Iran, any medical treatment, even super-specialized procedures, is considered necessary and permissible for all cosmetic surgeons, including general practitioners, provided that they have the necessary expertise. This has led to an increase in high-risk procedures, especially cosmetic surgeries, performed by general practitioners, even within the confines of their office. Consequently, complications and damages resulting from these procedures have increased, resulting in a majority of medical complaints related to general medical surgeries [2]. 
Examining unpublished medical malpractice records in Iran over the last three decades showed that the number of complaints against physicians has been on the rise. Changes in the medical system and the consumption of medical services have also led to a shift in the pattern of patients’ complaints about physicians. Nearly two-thirds of all medical malpractice cases are currently for cosmetic purposes, with rhinoplasty surgery being the most frequent cosmetic referral [3]. 
Although the surgeon knows that surgery is always associated with risks, the patient may not always be aware of this fact. As a result, adverse outcomes, whether they are real or imagined by the patient, are often the cause of filing a complaint against a significant percentage of physicians during their lifetime of practicing medicine. Due to the invasive nature of medical procedures, the surgical team is always the primary target of medical complaints [4]. Despite significant scientific advances and the presence of modern technology in the field of diagnostic and treatment services, international reports indicate that the number of complaints against medical physicians has been on the rise in different countries [5, 6]. Cosmetic surgery is often sought out for personal reasons, with many individuals seeking to correct and enhance their appearance, rid themselves of real or perceived defects, and make improvements to their self-esteem. People who suffer from anxiety disorders, depression, and low self-esteem are more likely to consider cosmetic surgeries [3, 7]. 
Cosmetic surgery is frequently performed to enhance psycho-social functioning, particularly in cases where physical symptoms are absent. Moreover, individuals who feel dissatisfied with their appearance are more likely to undergo cosmetic surgery. In current society, physical appearance has become a primary concern for people [1, 5, 8]. Despite being aware of the potential complications and risks associated with these procedures, some individuals accept them in order to gain a competitive edge in the realm of beauty. Bourdieu’s theory posits that cosmetic surgery has become a field of competition, where people strive to acquire more physical capital and a better life. Demand for beauty is partly due to cultural ideals that are imposed upon individuals and these individuals opt for cosmetic surgery due to normative pressures and the influence of media and reference groups, in order to enhance their quality of life and improve their social standing [9, 10]. 
Cosmetic surgery can create significant changes in an individual’s physical appearance, leading to a sense of satisfaction among surgery applicant. But it can lead to tissue necrosis, infections, embolism, reactions and even death [5, 6, 10]. The quality of one’s appearance is a crucial factor in determining their overall beauty, and it is influenced by their beliefs, ideas, and expectations. Therefore, it is important for individuals to determine their own appearance quality, rather than relying on others to do so. Mental well-being can be assessed to gauge an individual’s satisfaction with their physical appearance. Cosmetic surgery can help alleviate feelings of dissatisfaction and improve self-esteem by enhancing external appearance [11]. Appearance quality is an individual’s perception of their physical appearance and personal values regarding beauty. It is a reflection of the beauty that can be achieved through cosmetic surgery. In general, appearance quality refers to a person’s perception of their health and level of satisfaction with their physical appearance [12].
The increase in the popularity of cosmetic surgery in Iran has led to an upsurge in complaints from physicians. Therefore, this study aimed to investigate the appearance quality improvement of cosmetic surgery victims in forensic medical commissions in Tehran Province.

2. Materials and Methods 
Study type and study population 
In this mixed-method cross-sectional study, the appearance quality improvement, specifically aligning the surgery with the patient’s desired outcome was examined on complaints regarding cosmetic surgery within the framework of forensic medical commissions in Tehran Province during the period of 2020-2021. All participants in the study were individuals who had previously filed complaints with the Forensic Medicine Commission in 2019 and 2020, and their medical malpractice had been confirmed twice. From 980 medical compliant records, 276 sample size was determined using Morgan’s table. The sample was selected using non-probability convenient sampling method. 

Measures 
The first part of the questionnaire was complaints of cosmetic surgery victims based on the amount of damage that a person suffered from cosmetic surgery, such as nose surgery, drooping eyelids and eyebrows, liposuction (removal of excess fat), lifting (peeling), lip enhancement, cheek placement, and breast augmentation. All 14 items of victim complaints were extracted that was scaled using a 5-point Liker scale from very low=0 to very high=4.
The second part of the questionnaire was appearance quality that was measured based on two dimensions: 1) Satisfaction with appearance using 8 items and 2) Satisfaction with life using 12 items (Total items=20 items) 

Scoring
The score of each item was based on a 5-point Likert type scale ranging from “very little/not at all” (0) to “very much” (4). The score of each domain was calculated by summing up of all items. To better align with the limited scope of the data and the interpretation of the items, the data was divided into five classes: “very low,” “low,” “medium,” “high,” and “very high.” For example, to calculate the classes for appearance quality, which was measured by a combination of 20 items (8 items for satisfaction with appearance and 12 items for satisfaction with life) rated on a 0 to 4 scale, the lowest value (0) was subtracted from the highest value (80) and divided by 5 to obtain the following scales: 0-16, 16.1-32, 32.1-48, 48.1-64, and 64.1-80 [13]. Similarly, for satisfaction with appearance, which was measured by a combination of 8 items rated on a 0 to 4 scale, the lowest value (0) was subtracted from the highest value (32)and divided by 5 to obtain the following scales: 0-6.4, 6.5-12.8, 12.9-19.2, 19.3-25.6, and 25.7-32. Satisfaction with life, which was measured by a combination of 12 items also rated on a 0 to 4 scale, was similarly transformed into five classes by subtracting the lowest value (0) from the highest value (48) and dividing by 5 to obtain the following classes: 0-9.6, 9.7-19.2, 19.3-28.8, 28.9-38.4, and 38.5-48. Considering that 12 items have been designed to measure the variable of satisfaction with living conditions and for each item, a score between 0 and 4 has been assigned, so the potential scores are between 0 (12×0=0) and 48 (12×4=48). 
The reliability of the questionnaire was assessed on 35 sample. The Cronbach’ α associated with cosmetic surgery victims was 0.760 and appearance quality was 0.741. In terms of validity in the qualitative section, the credibility, defensibility, and trustworthiness of the groupings and coding were used to assess the research’s validity (CVI=0.911 and CVR=0.890). The consistency of the interview was determined by reviewers, and its validity was established by utilizing expert opinions.

Statistical analysis
The Kolmogorov–Smirnov test was used to assess normal distribution of the variables. Descriptive statistics were utilized to generate frequency tables, while inferential statistics were employed to explore the relationship between independent and dependent variables. Two-dimensional tables and the Pearson correlation coefficient test were utilized to determine the magnitude of the effect of independent variables and to ascertain whether such effects were significant. The measurement level of variables and statistical techniques were taken into account when analyzing the data from the two-dimensional tables and conducting the Pearson’s correlation test. The present study employed SPSS software, version 22 to analyze and process the quantitative findings.

3. Results
The mean age of the victims was 37.22±7.41 years (range:17-62 years). Regarding gender, 93.5% (n=258) was female and 6.5% (n=18) was male. The most age group was 28-37 years (43.1%). Regarding job, 40.2% (n=111) was self-employed. Others were 19.2 % (n=53) housewives, 0.4% (n=1) unemployed, 25.7% (n=71) employee, 2.2% (n=6) retired, 0.7% (n=2) disabled, 10.9% (n=30) student and 0.7% (n=2) unknown. In relation to appearance, the mean quality score was 28.59±8.68, with a median of 27. The mean satisfaction with life was 17.41±6.68 and its median was 16. The potential scores for satisfaction with appearance ranged from 0 to 32, with a mean score of 11.18±3.60 and a median score of 11 (Table 1).


Items of complaints among cosmetic surgery victims (14 items) and appearance quality (20 items) were presented in Tables 2 and 3.




To investigate the relationship between age and complaints about cosmetic surgery, we used Pearson’s test to measure the intensity and direction of the relationship. According to the Pearson test results, there is no significant relationship between age and cosmetic surgery complaints with a significance level of 0.864 (Table 4).


In order to investigate the relationship between the frequency of cosmetic surgery and complaints about cosmetic surgery, we used Pearson’s test to measure the intensity and direction of the relationship. According to the Pearson test results, there is a significant relationship between the frequency of cosmetic surgery and complaints about cosmetic surgery at a 95% confidence interval and with a significance level of 0.026, and based on the value of r=0.134, the relationship between the two variables is negative and very weak. In other words, the respondents (cosmetic surgery victims) who had less cosmetic surgery or had surgery for the first time were more malpractice and had a greater tendency to complain about cosmetic surgery (Table 4). The number of complaints about cosmetic surgery among the respondents who are unemployed and housewives is the highest and those who have a self-employed job are the lowest. There is a relationship between the improvement of the appearance quality of people who have undergone cosmetic surgery and the number of complaints they have about cosmetic surgery. There was a moderate and inverse significant correlation between appearance quality and complaints about cosmetic surgery (r=0.395, P<0.001). In fact, the higher satisfaction with appearance quality was associated with lower complaint about surgery. There was a significant relationship between the quality of appearance (satisfaction with appearance and life), dissatisfaction with surgery (P<0.001) (r=-0.330) and dissatisfaction with the case handling process (P<0.006) (r=-0.314) (Table 4).
To investigate the difference in the score of complaints about cosmetic surgery among occupational groups through F test (analysis of variance) in which unemployed (40.33±6.02) and then housewives (36.30±4.09) had higher mean score compared to employed (35.03±5.91), self-employed (33.97±5.03), retired (34±3.28) and students (34.93±6.20) (P=0.009).

4. Discussion 
The current investigation aimed to provide a sociological analysis of the enhancement of appearance quality in cosmetic surgery victims within the forensic medical commissions of Tehran Province. The study revealed a significant difference between the improvement of appearance quality of individuals who have undergone cosmetic surgery and the mean complaints they have about the procedure (r=-0.395). Our findings are consistent with the research conducted by Abbasi et al. (2015) [14], Haghshenas et al., (2012) [15], Enayat et al. (2020) [16], Samadian et al. (2019) [17], Furnham and Levitas [18], and Brown et al. (2007) [19], Imani et al. (2020) [20] and Hajiabllo et al. (2018) [21] suggest that the fear of possessing an imperfect figure or an unsuitable appearance and society’s value view of appearance and attractiveness contributes to the rise of dissatisfaction with appearance quality which was consisted of satisfaction with life and appearance. Cosmetic surgery, with its establishment of unrealistic expectations and deceptive factors, increases people’s desire for the procedure, resulting in an increase in complaints and dissatisfaction if the desired appearance is not achieved. 
Furthermore, Enayat et al. (2020) [16] believe that dissatisfaction with appearance and fears of losing beauty has led to an increased inclination towards surgery, which in turn increases the number of complaints and potential complications. 
It is true that social pressures and the desire to improve one’s appearance can be factors that influence a person’s decision to undergo cosmetic surgery. Many people feel that managing their body in this way can help them present a more desirable image that is accepted by society. However, it is important for individuals to make this decision based on their own personal values and goals, rather than solely on external pressures. Ultimately, the decision to undergo cosmetic surgery should be a personal one that is made with careful consideration and consultation with a qualified medical professional [15, 22, 23]. Mohammadshahi et al.’s research [24] and Furnham and Levitas [18] indicate that the decrease in quality of life and appearance quality, as well as the lack of support received after the procedure, mismatch of expectations with reality, and failures in the surgery, all contribute to an increased level of dissatisfaction and complaints, resulting in additional material and mental costs.
Many individuals who undergo cosmetic surgery do so because they have an unfavorable view of their appearance and feel pressure from others to conform to societal beauty standards. They hope that by improving their physical appearance through surgery, they will be able to communicate more easily and feel more confident in social situations. Unfortunately, if the surgery does not meet their expectations, they may experience even greater dissatisfaction and a further decline in their quality of life. This can lead to a loss of confidence, social isolation, and even damage to personal relationships [25]. Foucault and Navarro have argued that there is an instrumental power associated with the body, and that achieving an ideal body can lead to improvements in various aspects of life, such as professional and sexual life. However, failing to meet these ideals can result in feelings of deprivation, failure, and humiliation. If a person is unable to achieve their desired appearance through surgery, not only will their personal life be affected, but their social life may also suffer. As the results of the study indicate, many plaintiffs experienced a decline in their quality of life after surgery, which can be costly in terms of both financial and emotional well-being [26]. It is important for individuals considering cosmetic surgery to carefully weigh the potential benefits and risks, and to consult with a qualified medical professional before making any decisions. While surgery can help improve appearance and boost self-confidence, it is not a panacea for all problems and may not always lead to the desired outcomes [27].

5. Conclusion
According to the study, most people who had cosmetic surgery were only slightly satisfied with their living conditions and appearance. They believed surgery would improve their living conditions and social interactions, but actually faced challenges in family, finances, and health. If patients experience in the field of appearance quality increase, complaints from cosmetic surgeon decrease in medical commissions. Unemployed and housewives had the highest number of complaints, while self-employed people had the lowest. 

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Islamic Azad University, Science and Research Branch (IR.IAU.SRB.REC.1400.290).

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Authors' contributions
All authors equally contributed to preparing this article

Conflict of interest
The authors declared no conflict of interest..

Acknowledgements
The authors would like to thank Islamic Azad University, Science and Research Branch, for any support in the implementation of this research

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