- Email: [email protected]
Factors that affect the likelihood of undergoing cosmetic surgery
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Factors That Affect the Likelihood of Undergoing Cosmetic Surgery Amy Brown; Adrian Furnham; Louise Glanville, PhD; and Viren Swami, PhD Amy Brown is from the National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, United Kingdom. Adrian Furnham and Louise Glanville are from the Department of Psychology, University College, London, United Kingdom. Viren Swami is from the Division of Public Health, University of Liverpool, Liverpool, United Kingdom.
Background: With the rise in popularity of plastic surgery, it is useful to consider those factors that may increase the likelihood of undergoing cosmetic surgery in a nonpatient population. Objectives: A study was conducted to determine those factors that might motivate a nonclinical, nonpatient population to undergo cosmetic surgery. Methods: A sample of 119 women and 89 men, ages 18 to 59, was recruited from public spaces and asked to complete a questionnaire measuring how likely they were to consider undergoing the most common cosmetic procedures. Results: Women reported greater likelihood of undergoing cosmetic surgery than men, older men expressed less desire to undergo cosmetic surgery than younger men, and lower self-ratings of physical attractiveness predicted higher likelihood of undergoing cosmetic surgery. The vicarious experience of cosmetic surgery (via family and friends) increased the likelihood of undergoing cosmetic surgery for women, but not for men. Media exposure did not influence likelihood for either sex. Conclusions: Factors that affect the likelihood of undergoing cosmetic surgery vary with procedure; thus it would be valuable for future studies to use a scale that measures responses separately for different procedures. Lower self-ratings of physical attractiveness lead to consideration of cosmetic surgery; future studies may explore satisfaction levels of those who have undergone surgery. (Aesthetic Surg J 2007;27;501–508)
T
he popularity of cosmetic surgery has risen dramatically in recent years. The British Association of Aesthetic Plastic Surgeons recorded 22,041 procedures performed by its members in 2005 alone, representing a 34.6% increase from the previous year.1 Nor is this a uniquely European phenomenon. The American Society for Aesthetic Plastic Surgery reported that cosmetic procedures in the United States have increased by 446% since 1997.2 In 2006 alone, there were nearly 11.6 million cosmetic procedures performed in the United States.2 Sarwer et al3 have suggested 3 potential explanations for the marked increase in the popularity of cosmetic surgery: (1) recommendations by, and availability of, medical practitioners; (2) mass media and the entertainment industry; and (3) factors personally related to patients. However, of primary importance is that medical advances in cosmetic surgery have undoubtedly added to its popularity. Procedures are not only increasing in safety with the use of minimally invasive techniques but also demonstrating faster recovery. Both the
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facts contribute to a reduction in potential patients’ anxiety about undergoing procedures. Sarwer et al3 cite the influence of the media and entertainment industry in two ways. The recent surge of cosmetic surgery television programs, articles, and advertisements has raised public awareness of cosmetic surgery benefits and how to achieve them. A less direct media effect is in its portrayal of what currently constitutes ideal beauty.4 Contemporary societal ideals of physical attractiveness, at least in most socioeconomically developed settings, endorse ever slimmer, yet fullbreasted women—an ideal that may be unattainable by natural methods.5 Sarwer et al4 also suggest that patient behavior has fueled cosmetic surgery growth. The face of the typical patient undergoing cosmetic surgery has changed from the stereotype of the older Caucasian woman to men and women of all ages.6 This shift may be attributed to increased media attention on aesthetic surgery. Furthermore, the increase in patients undergoing aesthetic surgery results in many people personally knowing the
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type of person who has undergone cosmetic surgery. With the breakdown of the stereotype of the patient undergoing cosmetic surgery, the possibility of cosmetic surgery has been opened up to a wider population.7 Most of the research on psychological reasons for seeking cosmetic alteration and postoperative consequences of cosmetic surgery has relied on patient samples.8-11 In contrast, research in nonclinical or nonpatient samples that consider cosmetic surgery and the factors that influence its likelihood is sparse.12-13 With increasing patient numbers, awareness, and acceptance of cosmetic surgery, it is important to consider what motivates people to consider cosmetic procedures. A recent study by Delinsky7 addresses some of these issues. Female undergraduates completed a questionnaire measuring media exposure, personal and vicarious experience, acceptance, and likelihood of undergoing cosmetic surgery. A key finding was that the greater the vicarious experience of friends and family who had undergone cosmetic surgery, the greater the acceptance and likelihood of participants undergoing their own cosmetic surgery in the future. Delinsky7 offered a twofold explanation. First, vicarious experience increases information about cosmetic surgery and those who undergo it; this exposure has a normalizing effect. Second, experience of cosmetic surgery reduces negative stereotypes through increased familiarity, an idea consistent with the account of Sarwer et al4 of the increase in cosmetic procedures. In her study, Delinsky7 also found that media exposure significantly predicted approval and likelihood of undergoing cosmetic surgery. As with vicarious experience, media exposure may increase knowledge of, and familiarity with, cosmetic surgery and patients undergoing cosmetic surgery. Consequently, cosmetic surgery becomes an acceptable personal response to body dissatisfaction. However, it is also plausible that those more likely to undergo plastic surgery seek out related media information more than those who are negatively predisposed. In this study, we aim to further document, in a nonpatient sample, the spectrum of reasons for seeking cosmetic alteration. In Delinsky’s7 study, likelihood to undergo plastic surgery was measured by two response items. In our study, a new measure was developed to eliminate the restriction of cost. Furthermore, we asked participants to rate the likelihood of undergoing each of the most common cosmetic procedures separately. This is advantageous for two reasons; first, it allows participants to fully consider all the surgery possibilities; second, the effect of variables on individual procedures or groups of similar procedures can be studied separately.
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A further improvement is including a large number of male and female respondents (in contrast to Delinsky’s7 reliance on female respondents). While the previous sex bias is understandable (given the larger number of women undergoing cosmetic surgery), the number of men choosing to undergo surgery should not be ignored. In fact, men comprised 11% of the total of patients undergoing cosmetic surgery in the United Kingdom in 2005, up from 8% in 2004.1 However, we did hypothesize that women would report a greater likelihood to undergo cosmetic surgery compared with men. Delinsky’s7 participants, ranging in age from 18 to 33 years, were younger than ours. It is likely that there are age trends related to attitudes toward cosmetic surgery.12 Certainly, cosmetic surgery has been acceptable for women much longer than for men. Thus we hypothesized that older men would be less likely to consider undergoing cosmetic surgery. Moreover, age will obviously affect the likelihood of undergoing certain antiaging procedures, such as a face lift. Finally, we included a self-reported measure of physical attractiveness. On basis of the assumption that bodily or facial dissatisfaction is a strong motivation for considering cosmetic surgery,14-16 we hypothesized that lower self-ratings of attractiveness would predict a higher likelihood of undergoing surgery. To summarize, our hypotheses were as follow: (H1) women would report greater willingness to undergo cosmetic surgery than men; (H2) higher levels of media exposure and vicarious experience would be associated with greater likelihood of undergoing cosmetic surgery in both sexes; (H3) older men would be less likely to consider undergoing cosmetic surgery; (H4) age would have a differential effect for different cosmetic procedures; and (H5) lower self-ratings of attractiveness would predict greater likelihood of undergoing cosmetic surgery.
Participants Participants included 119 women and 89 men, ranging in age from 18 to 59 years (mean = 28.67, SD = 9.72); recruited opportunistically from a convenience sample. Most were of European Caucasian descent (84.2%), although other ethnic groups, including African Caribbean (5.4%) and Asian (5.9%), were also represented, and most had some university education (54.8%).
Measures Likelihood of having cosmetic surgery scale. Participants were instructed to imagine they had been awarded unlimited funds earmarked for cosmetic surgery
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procedures performed by highly regarded experts (Swami V, Furnham A. Likelihood of having cosmetic surgery scale. Unpublished questionnaire, University College London. 2006). They were then presented with a list of 49 of the most popular cosmetic procedures (culled from reputable cosmetic surgery clinics) and asked to rate their likeliness of undergoing each (Table 1). Likelihood or predisposition was reported on an 8-point scale (0 = no change under any circumstance, 7 = perform procedure). The questionnaire was tested as a pilot, using 18 participants. As a result, wording of some items was altered to ensure that all terms were understandable by a layperson. The “likelihood of having cosmetic surgery scale” was demonstrated to have very strong internal consistency (␣ = .95). Cosmetic surgery experiences. Exposure to cosmetic surgery media messages was measured by responses to 3 items. Following Delinsky,7 respondents were asked to rate on a 5-point scale (1 = never, 5 = very often), how often they had read articles or seen advertisements or television programs about cosmetic surgery. The measure had good scale reliability (␣ = .83). To measure personal experience, participants were asked whether they had ever undergone plastic surgery and, if so, to name the procedure(s). Vicarious experience was measured by asking participants, using a 5-point scale (1 = none, 2 = less than two, 3 = less than 10, 4 = more than 10, 5 = unsure), how many people they knew personally who had undergone elective cosmetic surgery. Because of the small number of participants who reported having undergone cosmetic surgery, this item was not included in any regression analyses. Self-ratings of attractiveness. Participants were asked to self-report their physical attractiveness on a 7point scale, ranging from 7 = very attractive to 1 = unattractive. Although single-item self-ratings of attractiveness have been criticized,17 they are widely used in body image research and show medium to high validity. Demographic variables. Participants were asked to report their age, sex, height, weight, ethnicity, and highest educational qualification.
Procedure Participants were recruited from public places (eg, train stations, libraries, cafeterias) and invited to take part in a study on cosmetic surgery. They participated voluntarily, were not remunerated, were tested individually, and provided informed consent. The order of the questionnaire was (1) “likelihood of having cosmetic surgery scale,” (2) cosmetic surgery experiences, (3) self-rating of attractive-
Factors That Affect the Likelihood of Undergoing Cosmetic Surgery
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ness, and finally (4) the demographic section. The procedure took about 15 minutes to complete and participants were debriefed after the experiment.
Results Descriptive statistics Cosmetic procedure items. The mean scores on the 8-point scale of all 52 procedure items are given in Table 1. Overall for women the highest scores were for 3 noninvasive procedures: teeth whitening (mean = 5.07, SD = 2.37); body hair removal (mean = 4.08, SD = 2.68); and facial hair removal (mean = 3.00, SD = 2.75). Of the invasive procedures, the highest scores were given for overall weight loss (through lipoplasty or fat removal) (mean = 2.65, SD = 2.59); anti-wrinkle (eyes) (mean = 2.50, SD = 2.22); and breast uplift (mean = 2.47, SD = 2.42). Overall for men, the highest scores for the noninvasive procedures were for teeth whitening (mean = 3.31, SD = 2.68); texture and appearance of skin (eg, minimize scars or sun damage) (mean = 1.30, SD = 1.93); and acne scarring reduction (mean = 1.06, SD = 1.71). Of the invasive procedures, the highest scores were for nose reshaping (rhinoplasty) (mean = 1.10, SD = 2.06); eyebag removal (mean = 1.07, SD = 1.88); and overall height increase (mean = .92, SD = 1.88). To test the association between likelihood of undergoing cosmetic surgery and the predictor variables, it was necessary to first generate composite scores for the predictor variables. The simplest way to do this was to calculate the mean response for all cosmetic procedure items. However, given that some items referred to male or female only procedures, we generated a “general likelihood” scale (of undergoing cosmetic surgery) by taking the mean of all items, excluding those limited to women or men (␣=.95). Personal and vicarious experience with cosmetic surgery. Of the 208 participants, 4 (1.9%) had person-
ally undergone cosmetic surgery, 41 (23.2%) did not know anyone who had undergone cosmetic surgery, 49 (27.7%) knew less than 2 people, 39 (22.0%) knew less than 10, 30 (16.9%) knew more than 10, and 17 (9.6%) were unsure. Media exposure to cosmetic surgery. Most participants reported at least some media exposure to cosmetic surgery; 67.8% reported having seen advertisements about cosmetic surgery at least sometimes, 54.8% reported reading articles about cosmetic surgery at least sometimes, and 62.7% had seen programs about cosmetic surgery at least sometimes.
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Table 1. Cosmetic procedure items and mean scores with standard deviations Body part/procedure* Face and head 1. Anti-wrinkle (forehead) 2. Anti-wrinkle (eyes) 3. Acne scarring reduction 4. Eye bag removal 5. Eyelid augmentation (blepharoplasty) 6. Nose reshaping (rhinoplasty) 7. Micropigmentation or dermagraphics (creates the appearance of semi-permanent make-up) 8. Brow or forehead lift 9. Lip implants 10. Lip reduction 11. Cheek implants 12. Chin augmentations (mentoplasty) 13. Teeth whitening 14. Ear pinning (otoplasty) 15. Face lift (rhytidectomy) 16. Facial hair removal 17. Hair implants 18. Scalp surgery Body (women and men) 19. Texture and appearance of skin (eg, minimize scars or sun damage) 20. Body hair removal 21. Skin color lightening 22. Skin color darkening 23. Overall weight loss (eg, through liposuction or fat removal) 24. Overall weight gain (eg, reshaping of body with fatty deposits) 25. Overall height increase 26. Overall height decrease 27. Neck augmentation 28. Width of shoulders increase 29. Length of arms 30. Biceps augmentation 31. Finger augmentation (eg, length or girth) 32. Fingernail augmentation 33. Nipple reshaping 34. Navel or belly button augmentation (umbilicoplasty) 35. Tummy tuck (abdominoplasty) 36. Waist augmentation (eg, with fat deposits) 37. Hip augmentation (eg, with fat deposits) 38. Buttock lift or implants 39. Thigh lift (thighplasty) 40. Calf implant 41. Length of legs 42. Feet augmentation (eg, size of feet) 43. Toenail augmentation Body (women only) 44. Breast enlargement 45. Breast reduction 46. Breast reconstruction 47. Breast uplift 48. Genital reshaping 49. Vaginal tightening Body (men only) 50. Breast reduction 51. Pectoral (chest muscles) implants 52. Genital augmentation (phalloplasty)
Mean (SD) Female (n = 119) Male (n = 89) 1.68 (1.05) .78 (0.87) 2.24 (2.11) .72 (1.40) 2.50 (2.22) .85 (1.59) 1.72 (1.90) 1.06 (1.71) 2.15 (2.23) 1.07 (1.88) 1.32 (1.76) .46 (1.12) 1.82 (2.22) 1.10 (2.06) 1.45 (1.85) .29 (.71) 1.22 (1.64) 1.21 (1.70) .61 (.79) .72 (1.11) .74 (1.14) 5.07 (2.37) 1.09 (1.71) 1.55 (1.96) 3.00 (2.75) 1.01 (1.63) .82 (1.25) 1.16 (0.88) 2.64 (2.38) 4.08 (2.68) .68 (1.09) 1.29 (1.78) 2.65 (2.59) .79 (1.50) 1.37 (2.06) .40 (0.54) .85 (1.42) .45 (.59) .54 (.93) .50 (.64) .46 (.65) 1.00 (1.67) .81 (1.27) .66 (1.08) 2.19 (2.54) 1.39 (1.99) 1.26 (1.87) 1.59 (2.09) 1.40 (1.94) .69 (1.30) 1.13 (1.83) .66 (1.19) .69 (1.24) 1.31 (1.14) 1.80 (2.22) .83 (1.39) 1.71 (2.19) 2.47 (2.42) .45 (.58) .61 (1.07)
.46 (1.08) .29 (.73 .25 (.53) .27 (.56) .45 (.97) 3.31 (2.68) .51 (1.01) .58 (1.32) .75 (1.59) .79 (1.54) .74 (1.47) .50 (.71) 1.30 (1.93) 1.00 (1.73) .28 (.64) .70 (1.57) .70 (1.39) .42 (.95) .92 (1.88) .28 (.77) .46 (1.19) .46 (1.13) .26 (.61) .61 (1.39) .36 (1.00) .31 (.76) .35 (.98) .33 (.94) .74 (1.57) .45 (1.10) .26 (.57) .57 (1.36) .34 (.84) .31 (.79) .27 (.60) .34 (.92) .39 (.98)
.53 (.96) .48 (1.18) .57 (1.26) .54 (1.18)
* Scale: 0 = No change under any circumstance, 7 = Perform procedure.
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Regression Analyses
To test the association of the hypothesized explanatory variables with the likelihood of having cosmetic surgery (“general likelihood”), stepwise multiple regressions analyses were conducted. The predictor variables that were used were sex, age, body mass index (calculated as kg/m2 from participants’ self-reported height and weight), media exposure, self-ratings of attractiveness, and vicarious experience with cosmetic surgery. Twoway interaction terms for gender, added in a second step in each regression, were built in with the other variables to provide for men and women being affected differently. These interaction terms were added in a second step in each regression. Table 2 shows the results from all the regression analyses. Sex, age, media exposure, self-ratings of attractiveness, and vicarious experience with cosmetic surgery were entered in Step 1. All 2-way sex interactions (sex ⫻ age, sex ⫻ media exposure, sex ⫻ self-ratings of attractiveness, sex ⫻ vicarious experience with cosmetic surgery) were entered in Step 2. Model 1 significantly predicted the likelihood of undergoing cosmetic surgery [F(5, 203) = 11.29, P < .05, R2 = .23). Examination of the individual  weights within this step revealed that only 2 variables significantly predicted this “general likelihood”: sex ( =.38, P < .05), with women scoring higher than men, and; self-ratings of attractiveness ( = -0.22, P < .05), with lower ratings of attractiveness predicting higher scores on likelihood of undergoing surgery. When the interaction terms were added, there was a significant R2 change [⌬R2 = .30, ⌬F(7, 199) = 10.11, P < .05]. Inspection of the individual  weights within this step revealed that the sex ⫻ vicarious experience interaction was significant ( = -1.06, P < .05) and the sex ⫻ age interaction fell just outside the significance limit ( = .52, P > .05). To reveal the nature of these interactions, the regression was run separately for men and women (with age, media exposure, self-ratings of attractiveness, and vicarious experience as predictor variables). For the women, the model accounted for 19% of the variance [F(3, 166) = 3.10, P < .05, R2=.19]. Media exposure and age were not significant. Self-ratings of attractiveness were significant ( = -0.26, P < .05), with lower ratings of attractiveness predicting higher scores on likelihood of undergoing surgery. Vicarious experience was a significant predictor of likelihood of undergoing surgery ( = .23, P < .05); the more people participants knew who had undergone cosmetic surgery, the more likely it was that they also would choose to undergo a procedure.
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For men, the model accounted for 19% of the variance [F(3, 86) = 2.16, P < .01, R2 = .19]. Media exposure was not significant. Self-ratings of attractiveness approached significance ( = -.20, P > .05), with low ratings of attractiveness predicting higher scores on likelihood of undergoing surgery. In contrast to female participants, age did significantly predict likelihood of undergoing cosmetic surgery ( = -.22, P < .05), with younger men more likely to undergo surgery. Finally, with men, the higher the scores of vicarious experience, the lower the scores on likelihood of undergoing surgery ( = -0.39, P < .01). Thus, the more people men knew who had undergone cosmetic surgery, the less likely they were to consider undergoing surgery themselves.
Discussion At the outset of this investigation, we formulated five testable hypotheses. Three of the hypotheses were supported: (H1) women reported greater likelihood of willingness to undergo cosmetic surgery than men; (H3) older men were less likely to express a desire to undergo cosmetic surgery, and; (H5) low self-ratings of physical attractiveness predicted increased likelihood of undergoing cosmetic surgery. Partial support was found for (H2): while vicarious experience increased the likelihood of having cosmetic surgery for women (but not for men), media exposure did not. There was also partial support for (H4): age showed a significant interaction with participants’ sex in predicting likelihood of undergoing cosmetic surgery. Finally, the high internal reliability of the general scale (including all male and female procedures) suggests that the scale was a successful tool for investigating attitudes toward cosmetic surgery. As expected, women reported significantly greater likelihood of undergoing cosmetic surgery than men. This is, perhaps, not surprising given the greater sociocultural pressure on women to attain ideals of physical and sexual attractiveness.18-20 Cultural pressures to conform to societal ideals of attractiveness are frequently pointed to in the literature as contributing to the higher prevalence of body image and eating disorders, at least in socioeconomically developed settings.21 The phenomenon of sex differences in societal pressures may lead more women to seek cosmetic surgery, which normalizes the process for women.7,22 But, the greater acceptance of cosmetic surgery among women may also be due to other factors. For example, cosmetic surgeons, recognizing gender differences in societal pressures, may specifically target women in their advertising. Nevertheless, as men increasingly become the subjects of societal ideals of attractive-
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Table 2. Results of regression analyses 
Predictors General likelihood (Step 1) Sex Age Media exposure Ratings of self-attractiveness Vicarious experience General likelihood (Step 2) Sex Age Media exposure Ratings of self-attractiveness Vicarious experience Sex ⫻ age Sex ⫻ media exposure Sex ⫻ vicarious experience General likelihood (women only) Age Media exposure Ratings of self-attractiveness Vicarious experience General likelihood (men only) Age Media exposure Ratings of self-attractiveness Vicarious experience

.69 .00 .07 ⫺.18 .00
.38* ⫺.03 .07 ⫺.22* .00
1.47 .04 .07 ⫺.17 ⫺.57 .02 .05 .37
.81* ⫺.44* .06 ⫺.21* ⫺.80* .52 .32 1.06*
.00 .15 ⫺.24 .17
.03 .15 ⫺.26* .23*
.02 .12 ⫺.11 .21
.22* .13 ⫺.20 .39*
R
R2
Adj R2
⌬R2
.48
.23
.21
.21
.55
.30
.27
.38
.14
.44
.19
⌬F
Df1
df2
11.29*
5
203
.03
6.00*
7
199
.11
.11
3.09*
3
116
.15
.15
4.95*
3
86
*P < .05
ness, it may be expected that openness to surgery among men may increase. Future research may consider in greater detail the extent of such sex differences. Contrary to our hypothesis, media exposure did not significantly predict likelihood to undergo cosmetic procedures. This is particularly surprising, because Delinsky7 found both approval and future likelihood of cosmetic surgery to be predicted by greater media exposure. One possible explanation is that media sources have become so saturated with cosmetic surgery messages that awareness has reached a peak. Cosmetic surgery messages may, therefore, no longer have the persuasive effect they once did. An alternative explanation is that media exposure is a better predictor of variables of personal relevance, such as specific plans to undergo future surgery, rather than general openness to cosmetic surgery. It is also plausible that it is not simple exposure that matters, but internalization of messages about cosmetic surgery that lead to greater likelihood of undergo-
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ing surgery. Thus it may be useful for future studies to include measures of internalizing media messages, rather than mere exposure ratings. Lower self-ratings of attractiveness predicted greater likelihood of undergoing cosmetic surgery. Those who felt themselves to be physically unattractive were more open to undergoing cosmetic surgery, which supports the notion that failure to attain societal ideals of attractiveness leads to greater body dissatisfaction and possibly to the consideration of cosmetic surgery.8 These findings may have implications for studies on body satisfaction and cosmetic surgery. For example, there is some evidence to suggest that some individuals who have undergone cosmetic surgery never attain full body satisfaction (Swami V, Furnham A. Likelihood of having cosmetic surgery scale. Unpublished questionnaire, University College London. 2006), which may lead to further procedures in an attempt to attain personal ideals of physical attractiveness.
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In terms of vicarious experience, a significant interaction was found with gender. Subsequent regressions, with men and women separately, found that the more people women knew who had undergone cosmetic surgery, the more likely they were to consider undergoing a cosmetic procedure. By contrast, the more people men knew who had undergone cosmetic surgery, the less likely they were to consider undergoing a cosmetic procedure. This is an important finding, because it indicates that men and women react differently to vicarious experience of cosmetic surgery. It is possible that men have had more negative vicarious experiences with cosmetic surgery (e.g., unhappiness with the physical or psychological results of surgery). It would be valuable for future research to investigate the causes of this sex difference. In this study, age showed a significant interaction with sex when predicting likelihood of undergoing cosmetic surgery. As expected, younger men were more likely to consider undergoing surgery than older men. Women, however, did not vary in their likelihood of undergoing cosmetic surgery as a function of age. That younger men were more likely to consider cosmetic surgery than older men can be explained by the recent rise in male cosmetic surgery,23 which, in turn, may be explained by the breakdown of the typically female stereotype of the cosmetic surgery patient. It is plausible that only the younger generation of men have rejected this stereotype, accounting for the effect of age found here. In terms of study limitations, note that participants constituted an opportunistic sample; it is therefore not possible to say what proportion of the sample would really be interested in cosmetic surgery. Moreover, the reality of choosing to undergo cosmetic surgery may be very different than the design of this study. For instance, those considering cosmetic surgery typically show an interest in one procedure, rather than choosing among a multitude of options. Similarly, the cost of cosmetic surgery can be limiting. Because of this, we asked participants to make their ratings free of this concern. However, this means our results predict likelihood of undergoing cosmetic surgery without monetary considerations and therefore cannot be generalized to actual decisions. The findings presented here have a number of applications. First, it has been highlighted that variables that affect the likelihood of undergoing cosmetic surgery vary with procedure. Thus it would be valuable for future studies to use a scale (such as the one used in this study) that measures responses for different procedures sepa-
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rately. Second, media exposure may not have a direct effect in considerations to undergo cosmetic surgery (although this may be mediated by internalization of media messages). Third, sex differences are not restricted simply to the number of men and women who have surgery, but also vary with age and vicarious experience. While this study adds to the growing body of literature on cosmetic surgery choices, it remains unclear whether the “variables leading to cosmetic surgery are positive, enabling women [people] to empower themselves by making physical changes to improve their selfimage and their lives; or whether they are pathological, causing women [and men] to take great risks to conform to unrealistic physical ideals.7 There is conflicting evidence as to whether patients experience significant psychological improvements after surgery,3 and there is always a medical risk when undergoing major surgery. Therefore it is unclear whether clinicians and researchers should view a consideration to undergo cosmetic surgery, and the variables that affect that consideration, as positive or negative.
Notes Because of the large number of cosmetic surgery items, it is also possible to conduct a factor analysis to reduce the number of items by combining two or more variables.25 Doing so would provide overall factor scores that could be used in regressional analyses. Although we conducted such a factor analysis, the results have not been reported here. ■ The authors have no financial disclosures with respect to the article. References 1. British Broadcasting Corporation. Big rise in cosmetic surgery ops. 2006. Online publication at: http://news.bbc.co.uk/1/hi/health/ 4609166.stm. Retrieved May 26, 2006. 2. American Society for Aesthetic Plastic Surgery. Quick Facts: Highlights of the ASAPS 2006 Statistics on Cosmetic Surgery. Online at: http://www.surgery.org. Retrieved June 6, 2007. 3. Sarwer DB, Magee L, Crerand CE. Cosmetic surgery and cosmetic medical treatment. In: Thompson JK, editor. Handbook of Eating Disorders and Obesity. Hoboken: John Wiley & Sons; 2004. pp. 71–96. 4. Sarwer DB, Grossbart TA, Didie ER. Beauty and society. In: Kaminer MS, Dover JS, Arndt KA, editors. Atlas of cosmetic surgery. Philadelphia: Saunders; 2002. p. 48–59. 5. Garner DM, Garfinkel PE, Schwartz D, Thompson M. Cultural expectations of thinness in women. Psychological Rep 1980;47:483–491. 6. Haiken E. Venus Envy: A History of Cosmetic Surgery. Baltimore: Johns Hopkins University Press; 1997. 7. Delinsky SS. Cosmetic surgery: a common and accepted form of selfimprovement? J Appl Soc Psychol 2005;35:2012–2028.
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8. Napolean A. The presentation of personalities in plastic surgery. Ann Plast Surg 1993;31:193–208. 9. Rankin M, Borah GL, Perry AW, Wey PD. Quality-of-life outcomes after cosmetic surgery. Plast Reconstr Surg 1998;102:2139–2145. 10. Edgerton MT, Jacobson WE, Meyer E. Surgical-psychiatric study of patients seeking plastic (cosmetic) surgery: ninety-eight consecutive patients with minimal deformity. Br J Plast Surg 1960;13:136–145. 11. Reich J. The surgery of appearance: psychological and related aspects. Med J Austr 1969;2:5–13. 12. Frederick DA, Lever J, Peplau LA. Interest in cosmetic surgery and body image: views of men and women across the lifespan. Plast Reconstr Surg (In press). 13. Simis KJ, Verhulst FC, Koot HM. Body image, psychosocial functioning, and personality: How different are adolescents and young adults applying for plastic surgery? Child Psychol Psychiatr 2001;42:669– 678. 14. Napolean A, Lewis CM. (1989). Psychological considerations in lipoplasty: The problematic or “special care” patient. Ann Plast Surg 1989;23:430–432. 15. Didie ER, Sarwer DB. Factors that influence the decision to undergo breast augmentation surgery. J Women’s Health 2003;12:241–253. 16. Henderson-King D, Henderson-King E. Acceptance of cosmetic surgery: Scale development and validation. Body Image 2005;2:137– 149. 17. Swami V, Furnham A, Georgiades C, Pang L. Evaluating self and partner physical attractiveness. Body Image 2007;4:97–101. 18. Cachelin FM, Striegel-Moore RH, Elder KA. Realistic weight perception and body size assessment in a racially diverse community sample of dieters. Obesity Res 1998;6:62-68. 19. Huon GF, Morris SE, Brown LB. Differences between male and female preferences for female body size. Austr Psychol 1990;25:314-317. 20. Zeller DA, Harner DE, Adler RL. Effects of eating abnormalities and Sex on perceptions of desirable body shape. J Abnormal Psychol 1989;98:93-96. 21. Dolan B. Cross-cultural aspects of anorexia nervosa and bulimia: a review. Int J Eating Disord 1989;10:67–79. 22. Sarwer DB, Magee L, Clark V. What is beauty? Physical appearance and cosmetic medical treatments: physiological and sociocultural influences. J Cosmetic Dermatol 2003;2:29–39. 23. Pertschuk MJ, Sarwer DB, Wadden TA, Whitaker LA. Body image dissatisfaction in male cosmetic surgery patients. Aesthetic Plast Surg 1998;22:20–24. 24. Howell D. Statistical Methods for Psychology. 5th ed. Belmont, CA: Duxbury Press; 2001. Accepted for publication May 3, 2007. Reprint requests: Dr. Viren Swami, Division of Public Health, University of Liverpool, Whelan Building, Quadrangle, Brownlow Hill, Liverpool L69 3GB. E-mail: [email protected]. Copyright © 2007 by The American Society for Aesthetic Plastic Surgery, Inc. 1090-820X/$32.00 doi:10.1016.j.asj.2007.06.004
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Factors That Affect the Likelihood of Undergoing Cosmetic Surgery Amy Brown; Adrian Furnham; Louise Glanville, PhD; and Viren Swami, PhD Amy Brown is from the National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, United Kingdom. Adrian Furnham and Louise Glanville are from the Department of Psychology, University College, London, United Kingdom. Viren Swami is from the Division of Public Health, University of Liverpool, Liverpool, United Kingdom.
Background: With the rise in popularity of plastic surgery, it is useful to consider those factors that may increase the likelihood of undergoing cosmetic surgery in a nonpatient population. Objectives: A study was conducted to determine those factors that might motivate a nonclinical, nonpatient population to undergo cosmetic surgery. Methods: A sample of 119 women and 89 men, ages 18 to 59, was recruited from public spaces and asked to complete a questionnaire measuring how likely they were to consider undergoing the most common cosmetic procedures. Results: Women reported greater likelihood of undergoing cosmetic surgery than men, older men expressed less desire to undergo cosmetic surgery than younger men, and lower self-ratings of physical attractiveness predicted higher likelihood of undergoing cosmetic surgery. The vicarious experience of cosmetic surgery (via family and friends) increased the likelihood of undergoing cosmetic surgery for women, but not for men. Media exposure did not influence likelihood for either sex. Conclusions: Factors that affect the likelihood of undergoing cosmetic surgery vary with procedure; thus it would be valuable for future studies to use a scale that measures responses separately for different procedures. Lower self-ratings of physical attractiveness lead to consideration of cosmetic surgery; future studies may explore satisfaction levels of those who have undergone surgery. (Aesthetic Surg J 2007;27;501–508)
T
he popularity of cosmetic surgery has risen dramatically in recent years. The British Association of Aesthetic Plastic Surgeons recorded 22,041 procedures performed by its members in 2005 alone, representing a 34.6% increase from the previous year.1 Nor is this a uniquely European phenomenon. The American Society for Aesthetic Plastic Surgery reported that cosmetic procedures in the United States have increased by 446% since 1997.2 In 2006 alone, there were nearly 11.6 million cosmetic procedures performed in the United States.2 Sarwer et al3 have suggested 3 potential explanations for the marked increase in the popularity of cosmetic surgery: (1) recommendations by, and availability of, medical practitioners; (2) mass media and the entertainment industry; and (3) factors personally related to patients. However, of primary importance is that medical advances in cosmetic surgery have undoubtedly added to its popularity. Procedures are not only increasing in safety with the use of minimally invasive techniques but also demonstrating faster recovery. Both the
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facts contribute to a reduction in potential patients’ anxiety about undergoing procedures. Sarwer et al3 cite the influence of the media and entertainment industry in two ways. The recent surge of cosmetic surgery television programs, articles, and advertisements has raised public awareness of cosmetic surgery benefits and how to achieve them. A less direct media effect is in its portrayal of what currently constitutes ideal beauty.4 Contemporary societal ideals of physical attractiveness, at least in most socioeconomically developed settings, endorse ever slimmer, yet fullbreasted women—an ideal that may be unattainable by natural methods.5 Sarwer et al4 also suggest that patient behavior has fueled cosmetic surgery growth. The face of the typical patient undergoing cosmetic surgery has changed from the stereotype of the older Caucasian woman to men and women of all ages.6 This shift may be attributed to increased media attention on aesthetic surgery. Furthermore, the increase in patients undergoing aesthetic surgery results in many people personally knowing the
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type of person who has undergone cosmetic surgery. With the breakdown of the stereotype of the patient undergoing cosmetic surgery, the possibility of cosmetic surgery has been opened up to a wider population.7 Most of the research on psychological reasons for seeking cosmetic alteration and postoperative consequences of cosmetic surgery has relied on patient samples.8-11 In contrast, research in nonclinical or nonpatient samples that consider cosmetic surgery and the factors that influence its likelihood is sparse.12-13 With increasing patient numbers, awareness, and acceptance of cosmetic surgery, it is important to consider what motivates people to consider cosmetic procedures. A recent study by Delinsky7 addresses some of these issues. Female undergraduates completed a questionnaire measuring media exposure, personal and vicarious experience, acceptance, and likelihood of undergoing cosmetic surgery. A key finding was that the greater the vicarious experience of friends and family who had undergone cosmetic surgery, the greater the acceptance and likelihood of participants undergoing their own cosmetic surgery in the future. Delinsky7 offered a twofold explanation. First, vicarious experience increases information about cosmetic surgery and those who undergo it; this exposure has a normalizing effect. Second, experience of cosmetic surgery reduces negative stereotypes through increased familiarity, an idea consistent with the account of Sarwer et al4 of the increase in cosmetic procedures. In her study, Delinsky7 also found that media exposure significantly predicted approval and likelihood of undergoing cosmetic surgery. As with vicarious experience, media exposure may increase knowledge of, and familiarity with, cosmetic surgery and patients undergoing cosmetic surgery. Consequently, cosmetic surgery becomes an acceptable personal response to body dissatisfaction. However, it is also plausible that those more likely to undergo plastic surgery seek out related media information more than those who are negatively predisposed. In this study, we aim to further document, in a nonpatient sample, the spectrum of reasons for seeking cosmetic alteration. In Delinsky’s7 study, likelihood to undergo plastic surgery was measured by two response items. In our study, a new measure was developed to eliminate the restriction of cost. Furthermore, we asked participants to rate the likelihood of undergoing each of the most common cosmetic procedures separately. This is advantageous for two reasons; first, it allows participants to fully consider all the surgery possibilities; second, the effect of variables on individual procedures or groups of similar procedures can be studied separately.
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A further improvement is including a large number of male and female respondents (in contrast to Delinsky’s7 reliance on female respondents). While the previous sex bias is understandable (given the larger number of women undergoing cosmetic surgery), the number of men choosing to undergo surgery should not be ignored. In fact, men comprised 11% of the total of patients undergoing cosmetic surgery in the United Kingdom in 2005, up from 8% in 2004.1 However, we did hypothesize that women would report a greater likelihood to undergo cosmetic surgery compared with men. Delinsky’s7 participants, ranging in age from 18 to 33 years, were younger than ours. It is likely that there are age trends related to attitudes toward cosmetic surgery.12 Certainly, cosmetic surgery has been acceptable for women much longer than for men. Thus we hypothesized that older men would be less likely to consider undergoing cosmetic surgery. Moreover, age will obviously affect the likelihood of undergoing certain antiaging procedures, such as a face lift. Finally, we included a self-reported measure of physical attractiveness. On basis of the assumption that bodily or facial dissatisfaction is a strong motivation for considering cosmetic surgery,14-16 we hypothesized that lower self-ratings of attractiveness would predict a higher likelihood of undergoing surgery. To summarize, our hypotheses were as follow: (H1) women would report greater willingness to undergo cosmetic surgery than men; (H2) higher levels of media exposure and vicarious experience would be associated with greater likelihood of undergoing cosmetic surgery in both sexes; (H3) older men would be less likely to consider undergoing cosmetic surgery; (H4) age would have a differential effect for different cosmetic procedures; and (H5) lower self-ratings of attractiveness would predict greater likelihood of undergoing cosmetic surgery.
Participants Participants included 119 women and 89 men, ranging in age from 18 to 59 years (mean = 28.67, SD = 9.72); recruited opportunistically from a convenience sample. Most were of European Caucasian descent (84.2%), although other ethnic groups, including African Caribbean (5.4%) and Asian (5.9%), were also represented, and most had some university education (54.8%).
Measures Likelihood of having cosmetic surgery scale. Participants were instructed to imagine they had been awarded unlimited funds earmarked for cosmetic surgery
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procedures performed by highly regarded experts (Swami V, Furnham A. Likelihood of having cosmetic surgery scale. Unpublished questionnaire, University College London. 2006). They were then presented with a list of 49 of the most popular cosmetic procedures (culled from reputable cosmetic surgery clinics) and asked to rate their likeliness of undergoing each (Table 1). Likelihood or predisposition was reported on an 8-point scale (0 = no change under any circumstance, 7 = perform procedure). The questionnaire was tested as a pilot, using 18 participants. As a result, wording of some items was altered to ensure that all terms were understandable by a layperson. The “likelihood of having cosmetic surgery scale” was demonstrated to have very strong internal consistency (␣ = .95). Cosmetic surgery experiences. Exposure to cosmetic surgery media messages was measured by responses to 3 items. Following Delinsky,7 respondents were asked to rate on a 5-point scale (1 = never, 5 = very often), how often they had read articles or seen advertisements or television programs about cosmetic surgery. The measure had good scale reliability (␣ = .83). To measure personal experience, participants were asked whether they had ever undergone plastic surgery and, if so, to name the procedure(s). Vicarious experience was measured by asking participants, using a 5-point scale (1 = none, 2 = less than two, 3 = less than 10, 4 = more than 10, 5 = unsure), how many people they knew personally who had undergone elective cosmetic surgery. Because of the small number of participants who reported having undergone cosmetic surgery, this item was not included in any regression analyses. Self-ratings of attractiveness. Participants were asked to self-report their physical attractiveness on a 7point scale, ranging from 7 = very attractive to 1 = unattractive. Although single-item self-ratings of attractiveness have been criticized,17 they are widely used in body image research and show medium to high validity. Demographic variables. Participants were asked to report their age, sex, height, weight, ethnicity, and highest educational qualification.
Procedure Participants were recruited from public places (eg, train stations, libraries, cafeterias) and invited to take part in a study on cosmetic surgery. They participated voluntarily, were not remunerated, were tested individually, and provided informed consent. The order of the questionnaire was (1) “likelihood of having cosmetic surgery scale,” (2) cosmetic surgery experiences, (3) self-rating of attractive-
Factors That Affect the Likelihood of Undergoing Cosmetic Surgery
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ness, and finally (4) the demographic section. The procedure took about 15 minutes to complete and participants were debriefed after the experiment.
Results Descriptive statistics Cosmetic procedure items. The mean scores on the 8-point scale of all 52 procedure items are given in Table 1. Overall for women the highest scores were for 3 noninvasive procedures: teeth whitening (mean = 5.07, SD = 2.37); body hair removal (mean = 4.08, SD = 2.68); and facial hair removal (mean = 3.00, SD = 2.75). Of the invasive procedures, the highest scores were given for overall weight loss (through lipoplasty or fat removal) (mean = 2.65, SD = 2.59); anti-wrinkle (eyes) (mean = 2.50, SD = 2.22); and breast uplift (mean = 2.47, SD = 2.42). Overall for men, the highest scores for the noninvasive procedures were for teeth whitening (mean = 3.31, SD = 2.68); texture and appearance of skin (eg, minimize scars or sun damage) (mean = 1.30, SD = 1.93); and acne scarring reduction (mean = 1.06, SD = 1.71). Of the invasive procedures, the highest scores were for nose reshaping (rhinoplasty) (mean = 1.10, SD = 2.06); eyebag removal (mean = 1.07, SD = 1.88); and overall height increase (mean = .92, SD = 1.88). To test the association between likelihood of undergoing cosmetic surgery and the predictor variables, it was necessary to first generate composite scores for the predictor variables. The simplest way to do this was to calculate the mean response for all cosmetic procedure items. However, given that some items referred to male or female only procedures, we generated a “general likelihood” scale (of undergoing cosmetic surgery) by taking the mean of all items, excluding those limited to women or men (␣=.95). Personal and vicarious experience with cosmetic surgery. Of the 208 participants, 4 (1.9%) had person-
ally undergone cosmetic surgery, 41 (23.2%) did not know anyone who had undergone cosmetic surgery, 49 (27.7%) knew less than 2 people, 39 (22.0%) knew less than 10, 30 (16.9%) knew more than 10, and 17 (9.6%) were unsure. Media exposure to cosmetic surgery. Most participants reported at least some media exposure to cosmetic surgery; 67.8% reported having seen advertisements about cosmetic surgery at least sometimes, 54.8% reported reading articles about cosmetic surgery at least sometimes, and 62.7% had seen programs about cosmetic surgery at least sometimes.
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Table 1. Cosmetic procedure items and mean scores with standard deviations Body part/procedure* Face and head 1. Anti-wrinkle (forehead) 2. Anti-wrinkle (eyes) 3. Acne scarring reduction 4. Eye bag removal 5. Eyelid augmentation (blepharoplasty) 6. Nose reshaping (rhinoplasty) 7. Micropigmentation or dermagraphics (creates the appearance of semi-permanent make-up) 8. Brow or forehead lift 9. Lip implants 10. Lip reduction 11. Cheek implants 12. Chin augmentations (mentoplasty) 13. Teeth whitening 14. Ear pinning (otoplasty) 15. Face lift (rhytidectomy) 16. Facial hair removal 17. Hair implants 18. Scalp surgery Body (women and men) 19. Texture and appearance of skin (eg, minimize scars or sun damage) 20. Body hair removal 21. Skin color lightening 22. Skin color darkening 23. Overall weight loss (eg, through liposuction or fat removal) 24. Overall weight gain (eg, reshaping of body with fatty deposits) 25. Overall height increase 26. Overall height decrease 27. Neck augmentation 28. Width of shoulders increase 29. Length of arms 30. Biceps augmentation 31. Finger augmentation (eg, length or girth) 32. Fingernail augmentation 33. Nipple reshaping 34. Navel or belly button augmentation (umbilicoplasty) 35. Tummy tuck (abdominoplasty) 36. Waist augmentation (eg, with fat deposits) 37. Hip augmentation (eg, with fat deposits) 38. Buttock lift or implants 39. Thigh lift (thighplasty) 40. Calf implant 41. Length of legs 42. Feet augmentation (eg, size of feet) 43. Toenail augmentation Body (women only) 44. Breast enlargement 45. Breast reduction 46. Breast reconstruction 47. Breast uplift 48. Genital reshaping 49. Vaginal tightening Body (men only) 50. Breast reduction 51. Pectoral (chest muscles) implants 52. Genital augmentation (phalloplasty)
Mean (SD) Female (n = 119) Male (n = 89) 1.68 (1.05) .78 (0.87) 2.24 (2.11) .72 (1.40) 2.50 (2.22) .85 (1.59) 1.72 (1.90) 1.06 (1.71) 2.15 (2.23) 1.07 (1.88) 1.32 (1.76) .46 (1.12) 1.82 (2.22) 1.10 (2.06) 1.45 (1.85) .29 (.71) 1.22 (1.64) 1.21 (1.70) .61 (.79) .72 (1.11) .74 (1.14) 5.07 (2.37) 1.09 (1.71) 1.55 (1.96) 3.00 (2.75) 1.01 (1.63) .82 (1.25) 1.16 (0.88) 2.64 (2.38) 4.08 (2.68) .68 (1.09) 1.29 (1.78) 2.65 (2.59) .79 (1.50) 1.37 (2.06) .40 (0.54) .85 (1.42) .45 (.59) .54 (.93) .50 (.64) .46 (.65) 1.00 (1.67) .81 (1.27) .66 (1.08) 2.19 (2.54) 1.39 (1.99) 1.26 (1.87) 1.59 (2.09) 1.40 (1.94) .69 (1.30) 1.13 (1.83) .66 (1.19) .69 (1.24) 1.31 (1.14) 1.80 (2.22) .83 (1.39) 1.71 (2.19) 2.47 (2.42) .45 (.58) .61 (1.07)
.46 (1.08) .29 (.73 .25 (.53) .27 (.56) .45 (.97) 3.31 (2.68) .51 (1.01) .58 (1.32) .75 (1.59) .79 (1.54) .74 (1.47) .50 (.71) 1.30 (1.93) 1.00 (1.73) .28 (.64) .70 (1.57) .70 (1.39) .42 (.95) .92 (1.88) .28 (.77) .46 (1.19) .46 (1.13) .26 (.61) .61 (1.39) .36 (1.00) .31 (.76) .35 (.98) .33 (.94) .74 (1.57) .45 (1.10) .26 (.57) .57 (1.36) .34 (.84) .31 (.79) .27 (.60) .34 (.92) .39 (.98)
.53 (.96) .48 (1.18) .57 (1.26) .54 (1.18)
* Scale: 0 = No change under any circumstance, 7 = Perform procedure.
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Regression Analyses
To test the association of the hypothesized explanatory variables with the likelihood of having cosmetic surgery (“general likelihood”), stepwise multiple regressions analyses were conducted. The predictor variables that were used were sex, age, body mass index (calculated as kg/m2 from participants’ self-reported height and weight), media exposure, self-ratings of attractiveness, and vicarious experience with cosmetic surgery. Twoway interaction terms for gender, added in a second step in each regression, were built in with the other variables to provide for men and women being affected differently. These interaction terms were added in a second step in each regression. Table 2 shows the results from all the regression analyses. Sex, age, media exposure, self-ratings of attractiveness, and vicarious experience with cosmetic surgery were entered in Step 1. All 2-way sex interactions (sex ⫻ age, sex ⫻ media exposure, sex ⫻ self-ratings of attractiveness, sex ⫻ vicarious experience with cosmetic surgery) were entered in Step 2. Model 1 significantly predicted the likelihood of undergoing cosmetic surgery [F(5, 203) = 11.29, P < .05, R2 = .23). Examination of the individual  weights within this step revealed that only 2 variables significantly predicted this “general likelihood”: sex ( =.38, P < .05), with women scoring higher than men, and; self-ratings of attractiveness ( = -0.22, P < .05), with lower ratings of attractiveness predicting higher scores on likelihood of undergoing surgery. When the interaction terms were added, there was a significant R2 change [⌬R2 = .30, ⌬F(7, 199) = 10.11, P < .05]. Inspection of the individual  weights within this step revealed that the sex ⫻ vicarious experience interaction was significant ( = -1.06, P < .05) and the sex ⫻ age interaction fell just outside the significance limit ( = .52, P > .05). To reveal the nature of these interactions, the regression was run separately for men and women (with age, media exposure, self-ratings of attractiveness, and vicarious experience as predictor variables). For the women, the model accounted for 19% of the variance [F(3, 166) = 3.10, P < .05, R2=.19]. Media exposure and age were not significant. Self-ratings of attractiveness were significant ( = -0.26, P < .05), with lower ratings of attractiveness predicting higher scores on likelihood of undergoing surgery. Vicarious experience was a significant predictor of likelihood of undergoing surgery ( = .23, P < .05); the more people participants knew who had undergone cosmetic surgery, the more likely it was that they also would choose to undergo a procedure.
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For men, the model accounted for 19% of the variance [F(3, 86) = 2.16, P < .01, R2 = .19]. Media exposure was not significant. Self-ratings of attractiveness approached significance ( = -.20, P > .05), with low ratings of attractiveness predicting higher scores on likelihood of undergoing surgery. In contrast to female participants, age did significantly predict likelihood of undergoing cosmetic surgery ( = -.22, P < .05), with younger men more likely to undergo surgery. Finally, with men, the higher the scores of vicarious experience, the lower the scores on likelihood of undergoing surgery ( = -0.39, P < .01). Thus, the more people men knew who had undergone cosmetic surgery, the less likely they were to consider undergoing surgery themselves.
Discussion At the outset of this investigation, we formulated five testable hypotheses. Three of the hypotheses were supported: (H1) women reported greater likelihood of willingness to undergo cosmetic surgery than men; (H3) older men were less likely to express a desire to undergo cosmetic surgery, and; (H5) low self-ratings of physical attractiveness predicted increased likelihood of undergoing cosmetic surgery. Partial support was found for (H2): while vicarious experience increased the likelihood of having cosmetic surgery for women (but not for men), media exposure did not. There was also partial support for (H4): age showed a significant interaction with participants’ sex in predicting likelihood of undergoing cosmetic surgery. Finally, the high internal reliability of the general scale (including all male and female procedures) suggests that the scale was a successful tool for investigating attitudes toward cosmetic surgery. As expected, women reported significantly greater likelihood of undergoing cosmetic surgery than men. This is, perhaps, not surprising given the greater sociocultural pressure on women to attain ideals of physical and sexual attractiveness.18-20 Cultural pressures to conform to societal ideals of attractiveness are frequently pointed to in the literature as contributing to the higher prevalence of body image and eating disorders, at least in socioeconomically developed settings.21 The phenomenon of sex differences in societal pressures may lead more women to seek cosmetic surgery, which normalizes the process for women.7,22 But, the greater acceptance of cosmetic surgery among women may also be due to other factors. For example, cosmetic surgeons, recognizing gender differences in societal pressures, may specifically target women in their advertising. Nevertheless, as men increasingly become the subjects of societal ideals of attractive-
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Table 2. Results of regression analyses 
Predictors General likelihood (Step 1) Sex Age Media exposure Ratings of self-attractiveness Vicarious experience General likelihood (Step 2) Sex Age Media exposure Ratings of self-attractiveness Vicarious experience Sex ⫻ age Sex ⫻ media exposure Sex ⫻ vicarious experience General likelihood (women only) Age Media exposure Ratings of self-attractiveness Vicarious experience General likelihood (men only) Age Media exposure Ratings of self-attractiveness Vicarious experience

.69 .00 .07 ⫺.18 .00
.38* ⫺.03 .07 ⫺.22* .00
1.47 .04 .07 ⫺.17 ⫺.57 .02 .05 .37
.81* ⫺.44* .06 ⫺.21* ⫺.80* .52 .32 1.06*
.00 .15 ⫺.24 .17
.03 .15 ⫺.26* .23*
.02 .12 ⫺.11 .21
.22* .13 ⫺.20 .39*
R
R2
Adj R2
⌬R2
.48
.23
.21
.21
.55
.30
.27
.38
.14
.44
.19
⌬F
Df1
df2
11.29*
5
203
.03
6.00*
7
199
.11
.11
3.09*
3
116
.15
.15
4.95*
3
86
*P < .05
ness, it may be expected that openness to surgery among men may increase. Future research may consider in greater detail the extent of such sex differences. Contrary to our hypothesis, media exposure did not significantly predict likelihood to undergo cosmetic procedures. This is particularly surprising, because Delinsky7 found both approval and future likelihood of cosmetic surgery to be predicted by greater media exposure. One possible explanation is that media sources have become so saturated with cosmetic surgery messages that awareness has reached a peak. Cosmetic surgery messages may, therefore, no longer have the persuasive effect they once did. An alternative explanation is that media exposure is a better predictor of variables of personal relevance, such as specific plans to undergo future surgery, rather than general openness to cosmetic surgery. It is also plausible that it is not simple exposure that matters, but internalization of messages about cosmetic surgery that lead to greater likelihood of undergo-
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ing surgery. Thus it may be useful for future studies to include measures of internalizing media messages, rather than mere exposure ratings. Lower self-ratings of attractiveness predicted greater likelihood of undergoing cosmetic surgery. Those who felt themselves to be physically unattractive were more open to undergoing cosmetic surgery, which supports the notion that failure to attain societal ideals of attractiveness leads to greater body dissatisfaction and possibly to the consideration of cosmetic surgery.8 These findings may have implications for studies on body satisfaction and cosmetic surgery. For example, there is some evidence to suggest that some individuals who have undergone cosmetic surgery never attain full body satisfaction (Swami V, Furnham A. Likelihood of having cosmetic surgery scale. Unpublished questionnaire, University College London. 2006), which may lead to further procedures in an attempt to attain personal ideals of physical attractiveness.
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In terms of vicarious experience, a significant interaction was found with gender. Subsequent regressions, with men and women separately, found that the more people women knew who had undergone cosmetic surgery, the more likely they were to consider undergoing a cosmetic procedure. By contrast, the more people men knew who had undergone cosmetic surgery, the less likely they were to consider undergoing a cosmetic procedure. This is an important finding, because it indicates that men and women react differently to vicarious experience of cosmetic surgery. It is possible that men have had more negative vicarious experiences with cosmetic surgery (e.g., unhappiness with the physical or psychological results of surgery). It would be valuable for future research to investigate the causes of this sex difference. In this study, age showed a significant interaction with sex when predicting likelihood of undergoing cosmetic surgery. As expected, younger men were more likely to consider undergoing surgery than older men. Women, however, did not vary in their likelihood of undergoing cosmetic surgery as a function of age. That younger men were more likely to consider cosmetic surgery than older men can be explained by the recent rise in male cosmetic surgery,23 which, in turn, may be explained by the breakdown of the typically female stereotype of the cosmetic surgery patient. It is plausible that only the younger generation of men have rejected this stereotype, accounting for the effect of age found here. In terms of study limitations, note that participants constituted an opportunistic sample; it is therefore not possible to say what proportion of the sample would really be interested in cosmetic surgery. Moreover, the reality of choosing to undergo cosmetic surgery may be very different than the design of this study. For instance, those considering cosmetic surgery typically show an interest in one procedure, rather than choosing among a multitude of options. Similarly, the cost of cosmetic surgery can be limiting. Because of this, we asked participants to make their ratings free of this concern. However, this means our results predict likelihood of undergoing cosmetic surgery without monetary considerations and therefore cannot be generalized to actual decisions. The findings presented here have a number of applications. First, it has been highlighted that variables that affect the likelihood of undergoing cosmetic surgery vary with procedure. Thus it would be valuable for future studies to use a scale (such as the one used in this study) that measures responses for different procedures sepa-
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rately. Second, media exposure may not have a direct effect in considerations to undergo cosmetic surgery (although this may be mediated by internalization of media messages). Third, sex differences are not restricted simply to the number of men and women who have surgery, but also vary with age and vicarious experience. While this study adds to the growing body of literature on cosmetic surgery choices, it remains unclear whether the “variables leading to cosmetic surgery are positive, enabling women [people] to empower themselves by making physical changes to improve their selfimage and their lives; or whether they are pathological, causing women [and men] to take great risks to conform to unrealistic physical ideals.7 There is conflicting evidence as to whether patients experience significant psychological improvements after surgery,3 and there is always a medical risk when undergoing major surgery. Therefore it is unclear whether clinicians and researchers should view a consideration to undergo cosmetic surgery, and the variables that affect that consideration, as positive or negative.
Notes Because of the large number of cosmetic surgery items, it is also possible to conduct a factor analysis to reduce the number of items by combining two or more variables.25 Doing so would provide overall factor scores that could be used in regressional analyses. Although we conducted such a factor analysis, the results have not been reported here. ■ The authors have no financial disclosures with respect to the article. References 1. British Broadcasting Corporation. Big rise in cosmetic surgery ops. 2006. Online publication at: http://news.bbc.co.uk/1/hi/health/ 4609166.stm. Retrieved May 26, 2006. 2. American Society for Aesthetic Plastic Surgery. Quick Facts: Highlights of the ASAPS 2006 Statistics on Cosmetic Surgery. Online at: http://www.surgery.org. Retrieved June 6, 2007. 3. Sarwer DB, Magee L, Crerand CE. Cosmetic surgery and cosmetic medical treatment. In: Thompson JK, editor. Handbook of Eating Disorders and Obesity. Hoboken: John Wiley & Sons; 2004. pp. 71–96. 4. Sarwer DB, Grossbart TA, Didie ER. Beauty and society. In: Kaminer MS, Dover JS, Arndt KA, editors. Atlas of cosmetic surgery. Philadelphia: Saunders; 2002. p. 48–59. 5. Garner DM, Garfinkel PE, Schwartz D, Thompson M. Cultural expectations of thinness in women. Psychological Rep 1980;47:483–491. 6. Haiken E. Venus Envy: A History of Cosmetic Surgery. Baltimore: Johns Hopkins University Press; 1997. 7. Delinsky SS. Cosmetic surgery: a common and accepted form of selfimprovement? J Appl Soc Psychol 2005;35:2012–2028.
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8. Napolean A. The presentation of personalities in plastic surgery. Ann Plast Surg 1993;31:193–208. 9. Rankin M, Borah GL, Perry AW, Wey PD. Quality-of-life outcomes after cosmetic surgery. Plast Reconstr Surg 1998;102:2139–2145. 10. Edgerton MT, Jacobson WE, Meyer E. Surgical-psychiatric study of patients seeking plastic (cosmetic) surgery: ninety-eight consecutive patients with minimal deformity. Br J Plast Surg 1960;13:136–145. 11. Reich J. The surgery of appearance: psychological and related aspects. Med J Austr 1969;2:5–13. 12. Frederick DA, Lever J, Peplau LA. Interest in cosmetic surgery and body image: views of men and women across the lifespan. Plast Reconstr Surg (In press). 13. Simis KJ, Verhulst FC, Koot HM. Body image, psychosocial functioning, and personality: How different are adolescents and young adults applying for plastic surgery? Child Psychol Psychiatr 2001;42:669– 678. 14. Napolean A, Lewis CM. (1989). Psychological considerations in lipoplasty: The problematic or “special care” patient. Ann Plast Surg 1989;23:430–432. 15. Didie ER, Sarwer DB. Factors that influence the decision to undergo breast augmentation surgery. J Women’s Health 2003;12:241–253. 16. Henderson-King D, Henderson-King E. Acceptance of cosmetic surgery: Scale development and validation. Body Image 2005;2:137– 149. 17. Swami V, Furnham A, Georgiades C, Pang L. Evaluating self and partner physical attractiveness. Body Image 2007;4:97–101. 18. Cachelin FM, Striegel-Moore RH, Elder KA. Realistic weight perception and body size assessment in a racially diverse community sample of dieters. Obesity Res 1998;6:62-68. 19. Huon GF, Morris SE, Brown LB. Differences between male and female preferences for female body size. Austr Psychol 1990;25:314-317. 20. Zeller DA, Harner DE, Adler RL. Effects of eating abnormalities and Sex on perceptions of desirable body shape. J Abnormal Psychol 1989;98:93-96. 21. Dolan B. Cross-cultural aspects of anorexia nervosa and bulimia: a review. Int J Eating Disord 1989;10:67–79. 22. Sarwer DB, Magee L, Clark V. What is beauty? Physical appearance and cosmetic medical treatments: physiological and sociocultural influences. J Cosmetic Dermatol 2003;2:29–39. 23. Pertschuk MJ, Sarwer DB, Wadden TA, Whitaker LA. Body image dissatisfaction in male cosmetic surgery patients. Aesthetic Plast Surg 1998;22:20–24. 24. Howell D. Statistical Methods for Psychology. 5th ed. Belmont, CA: Duxbury Press; 2001. Accepted for publication May 3, 2007. Reprint requests: Dr. Viren Swami, Division of Public Health, University of Liverpool, Whelan Building, Quadrangle, Brownlow Hill, Liverpool L69 3GB. E-mail: [email protected]. Copyright © 2007 by The American Society for Aesthetic Plastic Surgery, Inc. 1090-820X/$32.00 doi:10.1016.j.asj.2007.06.004
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