The nuances of diverse cultural mores and personal preferences present unique challenges for aesthetic practitioners when dealing with Middle Eastern patients. Wendy Lewis talks to a global panel of dermatologists and plastic surgeons about their experiences.
AIndustry OnsideIt IMCAS 2016 held in Paris in January, dermatologist Sahar Foad Ghannam, Professor of Dermatology at Alexandria University in Alexandria, Egypt, and Toronto dermatologist Ashraf Badawi, assembled a comprehensive program for the second year dedicated to an open exchange and discussion of the special needs of Middle Eastern patients, particularly women.
With the region’s rich history in cross-cultural integration, the Middle Eastern look encompasses a broad spectrum of skin tones and diverse heritage. ‘The natural geographic distribution of populations considered to have skin of color is extremely wide, encompassing Latin America, the Caribbean, Africa, Asia, and the Middle East. As such, people of skin of color constitute the majority of the world’s population,’ says Dr. Ghannam.
She explains that fine lines, deep lines, age spots, actinic keratoses and loss of elasticity are less severe in darker skin and occur later in life. ‘In darker skin types, lentigines, deep furrows, blotchy pigmentation, loss of elasticity and sagging are the main concerns that we see in Middle Eastern patients,’ she says. Other problems that patients complain about frequently are face and off face pigmentation, including the axilla, elbows, knees, hands, buttocks, and genital areas. Daily sun exposure and excessive heat contribute to these issues. ‘Because it is sunny 365 days per year, people should use extensive amount of sunscreen. Most patients use the amount of sunscreen that they are comfortable using. Educating people to apply a quantity that they feel is too much or too greasy will simply not work,’ she adds.
The wearing of a hijab, which is a form of head scarf, or a niqab, which covers the mouth and nose but leaving the eyes exposed but sometimes covering the eyes, can present irritation and hyperpigmentation that can be difficult to clear. The black dye of the cloth may cause staining of the skin of the cheeks, temporal hairline, and upper face that requires consistent use of topical beaching agents, a series of peels or lasers and light based energy devices, and daily usage of broad spectrum SPF for maintenance. ‘Sun avoidance in the Middle East is not a viable option. The only way to avoid sun exposure is to stay under your bed all day long,’ says Dr. Ghannam.
Perception of beauty
Beauty in the Middle East is still a very complex topic. The beauty ideals portrayed in the media are often considered the inspiration for women in the Arab world, and good looks are high on the agenda as an important source of pride.
Despite the fact that most women have to cover up in public, the demand for plastic surgery and cosmetic procedures has shown explosive growth over the past several years. Treatments have also become increasingly more accessible, affordable, and accepted. There is a growing trend for ‘slim’ to be the new standard of health, which also fuels the demand for cosmetic procedures like liposuction, breast augmentation and lifts, and tummy tucks.
‘There are several important motivators to consider for women. In the first place, there is a desire to keep one’s husband interested especially since he can marry more than once and divorce is quite common,’ says Dr. Ghannam.
The perception of beauty is evolving. It is becoming more synonymous with health and wellbeing, and women are more vocal about what they want. ‘There is definitely a profound emphasis on beauty in Arab culture, which originates from the region’s longstanding traditions. Women throughout the Middle East believe that taking better care of themselves and maintaining an attractive appearance is a priority for them,’ says Dr. Sam Rizk, a facial plastic surgeon in New York City. ‘The business of aesthetics in this market is very sophisticated. Consumers are looking for products and treatments that fulfill their goals and desires. It is also seen as a status symbol to indulge in luxury beauty and fashion.’
‘There is no denying that make-up is an important tool for women in the region, especially due to the fact that they are covered up most of the time with only their eyes showing. Cosmetics are seen as a way of self-expression that allow women to create their own personal style. There are many beauty trends that take prevalence in this region, including bold, dark eyebrows, full eyelashes, dark eyes, and long, thick hair,’ says Dr. Ghannam.
Women are flocking to cosmetic clinics to look like the Lebanese pop singing sensation and sex symbol Haifa Wehbe who recently turned 40 (haifawehbe.com), the equivalent of Sofia Vergara or Kim Kardashian. ‘They want her lips, nose, and large breasts with a tiny waist,’ says Dr. Ghannam.
‘In my experience, women in the Middle East tend to favor having larger eyes, and they accentuate the eyelid area by wearing false lashes and tattooed brows,’ says Dr. Rizk. ‘A common notion of beauty in the region is the desire to have an attractive body, full lips and a perfect nose, because it is perceived as what people aspire to be.’
Cosmetic enhancement trends
It is a world of BOTOX, breast implants, hair extensions, and heavy makeup. A far as body shape, women tend to want to keep their hour-glass figure and have some curves, without being overweight. Body contouring and liposuction are certainly growing in popularity. Icons like the former Queen Noor and current Queen Raina of Jordan are slender and beautiful. In some circles, women can be very competitive with each other, and cosmetic surgery has ceased to be a taboo subject and is now something to boast about.
According to Nelly Gauthier, an aesthetic doctor in Paris, ‘I have always had Middle Eastern patients coming to my clinic, but I have found that they have changed over the past few years. They used to be in awe of your knowledge and they blindly listened to your advice as a physician. They also were religiously faithful and took a conservative approach to treatments. More recently, I find that these patients are more suspicious about what the physician recommends. They will often jump from one clinic to the next, from one country to the next, doing a little bit of work in each clinic they visit.’
This behavior pattern presents a unique challenge for aesthetic practitioners in terms of being able to take a reliable history of the patient and knowing, for example, what fillers they have had and where, and what they are using on their skin topically or when the last time they had resurfacing performed.
‘Patients sometimes use over the counter bleaching creams sold on the Internet that may contain huge amounts of steroids that can cause atrophy, large concentrations of hydroquinone, and sometimes mercury, which is toxic. The patient then comes in when it doesn’t work or when they have a problem,’ says Dr. Ghannam.
‘One thing hasn’t changed, at least in my clinic,’ says Dr. Gauthier. ‘Many of my Middle Eastern patients are very demanding and high maintenance. They usually ask for “magic” and want you to make them look perfect. If you want to keep them as patients, being especially friendly is a must.’
Men seeking cosmetic enhancements are also on the rise. ‘I am also seeing more Middle Eastern men asking for injectable treatments and lasers. Those come alone, and I suspect they do not tell anyone,’ says Dr. Gauthier.
According to Dr. Ghannam, more men are asking for treatments as a solution to a condition they want to improve. ‘For example, a man may want to look less wrinkled because he is working with younger people or he is a Professor at a University and does not want to look older than his colleagues or students. They do not just come into the clinic asking for BOTOX, like women do. They are also having hair removal but not just for vanity alone. Men may complain about having irritation in certain areas or if they want to play sports,’ she adds. Acne scars and post-inflammatory hyperpigmentation are also of great concern.
Dr. Rizk reports that he is also seeing more men asking for upper and lower blepharoplasty, submental liposuction, neck lifts and rhinoplasty. ‘In my practice, the focus is in on noses and necks. Most women I see from the Middle East want a rhinoplasty, especially younger women. More mature women ask for face and neck lifts and blepharoplasty primarily. I have found that they like to hear terms like “rapid recovery”, “short scar lift”, and “mini jowl lift”, because it makes it sound less invasive. More recently, they are also going online to do research, and becoming much more knowledgeable about technological advancements.’
Compared with American patients, Dr. Rizk says, ‘I see a greater desire to have a prettier, smaller nose, which can be more challenging with thicker, sebaceous skin types so I use a 3D telescope approach for greater precision. They want their facelifts to look very natural and for the scars to be hidden. I also incorporate a highly concentrated form of PRP with all of my facelifts, which helps to improve skin quality.’
Doctor patient relationship
Culturally driven attitudes and behaviors often create communication challenges between Middle Eastern patients and health care professionals. These may include their approach to time control, power distance, male/female roles, personal space, and privacy1. Challenges may also develop around family involvement with patient care and handling how to deliver a diagnosis or treatment recommendation.
People from different cultures use space during conversation in unique ways. The appropriate conversational distance between Middle Easterners is twice as close as Americans are used to. Middle Easterners also tend to use touch more frequently. This erosion of personal space may feel invasive or even somewhat aggressive if the individuals are not used to it1,2.
Many people from the Middle East tend to resist disclosing detailed personal information to strangers, including doctors. Data for health histories may not be given willingly and request for information may be viewed with some suspicion until it is clear about why the questions are being asked. Once trust is established, personal information may be given more freely1. This tendency may make it difficult to get the details needed to form the optimal treatment plan for each individual patient.
There is also a resistance to having photographs taken, according to Dr. Hisham El Minawi, a plastic surgeon in Egypt. If the patient adamantly refuses, he asks the patient to sign a waiver indicating their refusal. ‘It is also common for the patient’s husband to be in the room when I am examining her breasts and body and pointing to the areas he wants improved,’ he says.
There is a desire to please or to appear good, and less dominant persons may need to placate stronger ones. This can be an important consideration especially between male doctors and their patients. Because the authority of a physician is not usually questioned, a Middle Eastern patient may be less likely to ask questions or give information that would contradict or show disrespect2. In some situations, men may also feel uncomfortable interacting with a female doctor according to Dr. Gauthier.
The challenges in establishing a doctor-patient relationship may include difficulty in obtaining adequate information from patients, sometimes demanding behavior of patients’ families, and less of a priority placed on planning ahead and punctuality, among other communication obstacles1. It is a sensitive culture and people are generally more conservative and private, which must be respected. It is usually appropriate to speak first to the family spokesman. The one with the most authority in any situation is usually the oldest and most educated person1. It may be necessary to assign female staff and caregivers to communicate with female patients, and males with males, whenever possible.
It is also important for practitioners to be sensitive to preserving a woman’s modesty at all times. Direct eye contact with members of the opposite sex may be misinterpreted, particularly from female to male. Personal problems and concerns are usually taken care of within the family and kept private. Negative information needs to be presented with great care, and anything that could be considered bad news may not always be given to the patient directly1.
Given the intensity of interpersonal relationships, Middle Eastern patients tend to communicate through arriving at an understanding of events by examining the context in which they occur. For example, they may need to know more about a person for a relationship to develop. By contrast, in the U.S., emphasis is placed on the verbal message and less so on the context in which the message is given.
Punctuality is less important in the Middle East than in the U.S. and many European countries. A patient might be late for an appointment, or not come at all, because something else arose. Middle Eastern patients may be offended by imposing the expectation of arriving in a timely fashion or being rushed. There is a priority based on taking the time to establish a long-term personal relationship1,2.
Middle Eastern women often tend to come to an aesthetic practice with an entourage. ‘They always come with friends and/or family. When I have an appointment scheduled for one patient, I usually expect a minimum of three to show up who will all want to be seen and treated as well,’ says Dr. Gauthier. ‘The husbands usually come to the first consultation only, mainly to reinforce their position. Husbands may also answer questions addressed to their wives.’ Women may defer to their husbands for decision-making regarding their own treatment, which is not necessarily a sign of dominance on the part of the male. In some cases, the women may prefer this culturally based dynamic. ‘But I have found that the men will usually let their wives do whatever they want and seem disinterested throughout the visit,’ she adds.
Social media soars
As the Middle East is a relationship-based culture, being active on social channels offers a new way to maintain personal contacts as well as to establish new relationships. Video sharing has exploded because it allows for real people and real company or brand representatives to communicate directly with their target audiences.
The region scores high penetration rates in social media. As of the end of 2015, there were over 41 million active users in the Middle East3. As expected, the young, tech-savvy generation is driving these high rates of social media consumption.
According to Ashraf Badawi, MD, PhD, Assistant Professor of Dermatology, Laser Institute, Cairo University, Egypt, social media has taken off in the region and has changed the way doctors must practice in the Middle East and what patients are asking for. Patients are online 24/7 and looking at Facebook, Twitter, Instagram and now Snapchat. Snapchat has surpassed Instagram as the leading platform of choice for social media influencers in the region with record annual growth. WhatsApp is also extremely popular, and the vast majority of social media users communicate on mobile devices.
Dr. Ghannam has also witnessed this trend. ‘The rise in social media platforms is making patients more self-conscious about how they look. They sometimes ask for the “Nefertiti look” or the “Texas look”, even though they do not know what it even means,’ she says.
Beauty bloggers and vloggers in the region are huge influencers of these trends. If a blogger posts a picture with a dermatologist or cosmetic doctor, they can gain instant recognition. Among the influencers to watch, Sondos Al Qattan from Kuwait (instagram.com/sondos_aq) has over 2M followers that look to her for advice on cosmetics.
Huda Heidi Kattan (HudaBeauty.com), a celebrity makeup artist in Dubai, has 13M loyal fans who watch her tutorials and read her blog and Instagram for beauty tips4. Sephora Middle East engaged her for a social media competition for three girls to win a makeover and spend the day with the famous beauty blogger. Videos were distributed on Sephora Middle East’s social media channels and on her blog.
The crop of beauty influencers are poised to continue to grow as more and more users seek out their content. New content creation tools and platforms are also expected to make it easier to consume their beauty-related content. However, as influencers keep gaining traction, the bar will be raised for attaining higher levels of fans. A million followers may not cut it in the near future.
Doctors can also rise to the status of Instagram stars. Dermatologist Alaa Aref of Reddah, Saudi Arabia, has amassed 110,000 followers and posts about skin and beauty-related issues, treatments, and celebrity trends. She credits PRIME for her social media prowess, having been inspired by our frequent social media features which stimulated her interest.
In conclusion, says Dr. Ghannam, ‘We are faced with the challenge of providing services in a culturally sensitive manner. By being aware of the common traditions, beliefs and practices in that society, the aesthetic practitioner can reduce the barriers and gain patient trust to build up good rapport.’