University of Alabama

May 12, 2022

Ross L Pearlman,1 Amanda H Wilkerson,2 Emily K Cobb,1 Summer Morrissette,1 Frances G Lawson,1 Chelsea S Mockbee,1 Laura S Humphries,3 Kimberley HM Ward,1 Vinayak K Nahar1,4,5 1Department of Dermatology, School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA; 2Department of Health Science, College of Human Environmental Sciences, The University of Alabama, Tuscaloosa, AL, USA; 3Division of Plastic Surgery, School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA; 4Department of Preventive Medicine, School of Medicine/John D. Bower School of Population Health, University of Mississippi Medical Center, Jackson, MS, USA; 5Department of Clinical Research, School of Graduate Studies in the Health Sciences, University of Mississippi Medical Center, Jackson, MS, USA Correspondence: Vinayak K Nahar, Department of Dermatology, School of Medicine, University of Mississippi Medical Center, 2500 North State Street – L216, Jackson, MS, 39216, USA, Tel +1 601 495-5876, Email [email protected] Introduction/Goals: Over the past decade, cosmetic surgical procedures have become increasingly popular. This trend has been driven by procedural innovations as well as access to Internet and social media. Consequently, patients have been seeking cosmetic surgical procedures at younger ages. In this narrative review, studies assessing attitudes towards cosmetic surgical procedures among college-aged young adults were evaluated. Methods: A search identified 20 studies published from 2002 to 2021 that focused on cosmetic surgical procedures among young adults. Each study used survey-based data to determine attitudes, acceptance, interests, perceptions, and beliefs about cosmetic surgical procedures among college-aged students in the United States. Results: The proportion of college-aged participants who had undergone cosmetic surgical procedures ranged from 1.3% to 6.4% with surveys reporting that between 21 and 43% were interested in procedures in the future. In general, young women were more likely to express interest in cosmetic surgical procedures than young men. Studies consistently demonstrated an inverse relationship between body satisfaction and use of aesthetic procedures among this patient population. Other factors associated with acceptance and approval of cosmetic surgical procedures included importance of appearance to self-worth, concern with social standing and attractiveness, investment in appearance, media influence on body image, and positive attitudes towards celebrities. Exposure to cosmetic surgery advertising was correlated with increased approval of cosmetic surgical procedures, especially the perception that advertising influences “others” more than survey respondents themselves. Conclusion: Interest in cosmetic surgical procedures continues to grow among young adults in the United States. In the future, this cohort is likely to become an increasingly important demographic to target for education, advertising, and research regarding cosmetic surgical procedures. Keywords: college students, young adults, cosmetic procedure, cosmetic surgery, factors, review Introduction Interest in cosmetic surgical procedures in the United States has steadily increased in recent years. 1 , 2 The American Society of Plastic Surgeons (ASPS) reported that its members performed a total of 15,595,955 cosmetic surgical procedures in 2020. This total comprised approximately 2,314,720 cosmetic surgical procedures including augmentation mammoplasty, blepharoplasty, rhytidectomy, liposuction, and rhinoplasty and 13,281,235 minimally invasive cosmetic surgical procedures including neuromodulator injections, soft tissue filler injections, and chemical peels. 3 Cosmetic surgical procedures are focused on creating balanced body features, as well as enhancing personal appearance. 4 Compared to minimally invasive techniques, surgeries require longer recovery time and are often performed under sedation. Thus, minimally invasive techniques are desired by patients due to their ability to create a youthful appearance with less risk and postoperative downtime compared to surgical techniques. 5 The 2018 Plastic Surgery Statistics Report found that 92% of all cosmetic surgical procedures were performed on women. While the most popular cosmetic surgical procedures performed on women were breast augmentation and liposuction, men more commonly underwent rhinoplasty and blepharoplasty. The most common minimally invasive cosmetic surgical procedure performed was neurotoxin injection (eg, Botox, Dysport, Xeomin). The ASPS calculated a total of 6,984,566 women and 452,812 men received neurotoxin injections in 2018. 6 These numbers reflect the reported procedures from members of the ASPS alone. Meanwhile, the American Society for Dermatologic Surgery (ASDS) reported about 2.1 million neurotoxin injections by dermatologists in 2018. 1 Other physicians and physician-extenders also perform many of these procedures each year with recent surveys finding that 22% of primary care physicians are offering cosmetic surgical procedures in their office. 7 While cosmetic surgery has traditionally been associated with middle-aged patients, many cosmetic surgery patients today are younger. In 2018, the ASPS reported approximately 3,966,419 patients who underwent either cosmetic surgery or a minimally invasive procedure were 39 years old or younger. 6 Of these, 831,775 were between the ages of 20 and 29, representing a 1% increase from 2017. Breast augmentation, rhinoplasty, and liposuction were the top three most common cosmetic surgeries in this age group. Laser hair removal, neurotoxin injection, and soft tissue fillers were the most common minimally invasive cosmetic surgical procedures sought by this age group. 3 , 6 The 2020 Aesthetic Plastic Surgery Statistics corroborated these findings showing that the top surgery performed in patients from ages 17–35 was breast augmentation with a total of 127,431 patients in this age range. 8 One study of millennial-aged patients (ie born 1981–1996) in a New York-based private practice found a greater than 50% increase in the average number of minimally invasive cosmetic surgical procedures performed on this age group from 2015 to 2020. Regarding neurotoxin injections, the authors suggest that young patients have recently become interested in the concept of “pretreatment” of facial rhytids to prevent static rhytid formation in the future. 9 This trend was likely accelerated by an increasing diversity and availability of procedures, decreasing costs, and expanding representation of these procedures on the Internet and social media. 10 In 2005, many individuals were regularly accessing the Internet, but only a miniscule 5% of Internet consumers were using social media. By 2011, that number had risen to include half of Americans. Today, around 72% of Americans use social media. 11 Access to social media, combined with the increased visibility of cosmetic dermatologists and plastic surgeons, resulted in potential patients having substantial access to information about procedures. 9 A recent Google trend search of key cosmetic terms and procedures from January 2004 to December 2017 showed increasing popularity of searching terms such as “dermatologist,” “Botox,” and “Juvederm.” Use of these terms was significantly associated with use of both Facebook and Instagram platforms. 10 Both psychological and emotional factors likely play a role in motivation to undergo cosmetic surgery. 12 Societal acceptance appears to be a common motivator that prompts patients to seek cosmetic surgical procedures. 13 With increasing availability of media, viewers are bombarded with societal opinions of beauty as well as attitudes towards cosmetic surgical procedures. Of note, the probability of a patient undergoing a cosmetic surgical procedure varies with the type of procedure selected. 12 A common theme found in these patients was that those who rated themselves lower on the attractiveness scale were more likely to undergo cosmetic surgical procedure. Boosting self-confidence through improvement in body image is a major motivator for the use of cosmetic surgical procedure. 14 , 15 A number of studies have investigated the attitudes, interests, and beliefs related to cosmetic surgical procedures among college-aged students in the United States. This review attempts to collate these findings among this unique cohort. Understanding the psychological and social determinants of attitudes towards cosmetic surgical procedure will help guide future progress towards providing adequate and appropriate cosmetic options to this age group. This paper presents a narrative review of research relating to the attitudes about cosmetic surgical procedure among college students in the United States to investigate the factors influencing college students’ intentions to undergo cosmetic surgical procedure and provide a clear direction for future research in this area. Methods The following inclusion criteria were used for study selection: 1) all study designs were considered; 2) study participants were United States college students; 3) the studies measured the elements leading to acceptance of cosmetic surgical procedures; 4) there were no constraints on the date of publication; 5) there was consideration of only English studies; 6) only publications in peer-reviewed journals were selected; and 7) the studies consisted of complete data for extraction. Study exclusion criteria included the following: 1) studies in duplicate; 2) literature reviews; 3) ongoing studies or incomplete studies; 4) conference abstracts; 5) clinical features or treatment-centered studies; and 6) studies that did not sample United States college students. Two independent reviewers used a myriad of search strategies to locate studies in June 2021. To ensure every possible study was obtained, previous literature related to cosmetic procedures was explored in order to derive applicable keywords; combinations of the following keywords were used in the search: “cosmetic procedures,” “cosmetic surgery,” “college students,” and “aesthetic procedures.” Three bibliographic electronic databases (ie, PubMed, NCBI, ScienceDirect) were used to perform a comprehensive search and identify potentially pertinent articles. The University of Mississippi library databases and Google Scholar were additionally used to confirm no studies were inadvertently overlooked. The full texts, including the titles and abstracts, were reviewed to determine if studies met the inclusion and exclusion criteria. The primary literature citations were inspected as a potential extra source of studies related to cosmetic surgical procedures. After all search options were exhausted and an extensive number of articles obtained, the final compilation of relevant literature was screened to ensure study eligibility based on previously established criteria. The two independent reviewers discussed any discrepancies between study eligibility. Once a consensus was reached, the two reviewers read through the selected studies in their entirety and selected the relevant information from each article. Once again, the two reviewers came together to analyze the independently gathered data and discuss any inconsistencies. A total of 485 references were identified from the previously discussed electronic-based studies. Of these, 66 articles remained after removing duplicates and scanning the titles and abstracts for applicability to the study. Using previously established eligibility criteria, the 66 studies read in full text were further narrowed down, removing 47 studies from the pool. At the conclusion of this search, 20 articles were determined to meet all inclusion criteria. The literature search process is illustrated in Figure 1 . Study outcomes were organized and analyzed into the following categories: 1) factors associated with likeliness to pursue cosmetic surgical procedure; 2) positive and negative attitudes toward cosmetic surgical procedure; 3) acceptance of cosmetic surgical procedure; and 4) perception of others who undergo cosmetic surgical procedure, the surgical profession, and representation of cosmetic surgery by the media. Figure 1 Literature search process. Results A total of 20 studies published from 2002 to 2021 were reviewed. 16–35 Table 1 presents detailed information extracted from each study. Table 1 Summary of Studies Reviewed Sample Size and Demographics All 20 studies used survey-based data collection methods to determine attitudes, acceptance, interests, perceptions, and/or beliefs about cosmetic surgical procedure among college students in the United States. Sample size ranged from 101 to 2057. 27 , 34 Nine studies included only female college students in the sample, 19 , 20 , 23 , 24 , 26 , 27 , 33–35 whereas the remaining 11 studies 16–18 , 21 , 22 , 25 , 28–32 had predominantly female samples, ranging from 54% 31 , 32 to 75% 30 of the sample identifying as female. Regarding race and ethnicity, 13 studies included predominantly white samples, 16 , 17 , 19 , 24–31 , 34 , 35 with as low as 54% 19 to as high as 86.8% 26 of the sample identifying as white. Factors Associated with Likeliness to Pursue Cosmetic Surgical Procedure Five studies reported the proportion of participants who had undergone cosmetic surgical procedures for both cosmetic and reconstructive purposes, 18 , 20 , 29 , 33 , 34 from as few as 1.3% 18 to as high as 6.4%. 34 Participants’ interest in receiving cosmetic surgery in the future was assessed in 16 studies ( Table 1 ). 22 , 23 , 27–29 , 31–35 Among participants who had not undergone cosmetic surgical procedures, the proportion interested in pursuing cosmetic surgical procedure in the near future ranged from 21% 20 to 43%. 27 In one study, 4.8% of the participants expressed interest in receiving cosmetic surgical procedure if their partner encouraged the procedure, and 28.4% agreed that they would have cosmetic surgical procedure if they had an unlimited amount of money. 33 Considerations associated with future intention to undergo cosmetic surgical procedure varied. These factors were categorized into demographic, intrapersonal, interpersonal, and societal. Among demographic factors, gender and racial identity were found to be associated with intention to pursue cosmetic surgical procedure in a few of the reviewed studies. In three studies, 17 , 21 , 22 women were more likely than men to express interest in cosmetic surgical procedure. Only one study 22 found an association between racial identity and intention to pursue cosmetic surgical procedures, where participants who identified as Latin American/Hispanic reported greater interest in pursuing cosmetic surgical procedure when compared to participants who identified as Asian American, Asian, or Pacific Islander. Intrapersonal characteristics and perceptions were associated with increased intentions to pursue cosmetic surgical procedures, including the importance of virtue, or “doing the right thing,” to self-worth, 20 perfectionism, 20 self-consciousness, 20 realism, 21 fear of becoming unattractive, 25 appearance rejection sensitivity, 31 , 32 body mass index (BMI), 23 , 24 and appearance fixing coping. 18 Further, several individual weight-related behaviors and perceptions were associated with increased intentions such as body dissatisfaction, 18 , 23 , 26 , 27 body shame, 23 dieting, 19 and disordered eating. 19 , 23 Conversely, in one study, 28 body satisfaction was found to be associated with lower intention to pursue cosmetic surgical procedure. Increased intention was also associated with various interpersonal factors, including experiencing teasing about physical appearance, 27 interpersonal experiences with cosmetic surgical procedure, 30 and paternal attitudes towards cosmetic surgical procedures. 24 At the societal level, media exposure, 20 , 27 , 35 internalization of sociocultural attitudes toward appearance, 20 , 24 cosmetic surgery makeover programs, 28 , 34 and celebrity worship 26 were all associated with increased intention to receive cosmetic surgical procedure. Positive and Negative Attitudes Toward Cosmetic Surgical Procedure Five studies assessed participants’ attitude and beliefs towards cosmetic surgical procedure. 29 , 30 , 33–35 Sarwer et al 33 reported positive attitudes towards undergoing cosmetic surgical procedure to increase self-esteem (40.2%) and to feel better (45.1%), as well as negative attitudes including beliefs that cosmetic surgical procedure is a waste of money (32.9%) and embarrassment to tell family and friends about undergoing cosmetic surgery (53.6%). Attitude towards cosmetic surgical procedure was found to be positively related to investment in appearance, 33 mass media influence on body image, 33 weight concerns, 33 physical comparison to others, 33 extreme makeover show viewing, 34 low self-esteem, 30 and exposure to cosmetic surgery media. 35 A negative relationship was associated with perceived risk. 30 Additionally, Park and Allgayer 29 assessed college students’ attitudes towards cosmetic surgeons and found lower confidence and less favorable views about cosmetic surgeons when compared to other physicians. One study assessed beliefs about the risk of cosmetic surgical procedure and found women exhibited higher perceived risk when compared to men. 29 Acceptance of Cosmetic Surgical Procedure Acceptance of cosmetic surgical procedure was assessed in seven of the reviewed studies. 17 , 20 , 24–26 , 30 , 33 Factors positively associated with acceptance and approval of cosmetic surgical procedure were importance of appearance to self-worth, 20 low self-esteem, 20 , 24 , 25 , 30 concern with social standing, 25 concern with own attractiveness, 25 approval of socio-cultural attitudes towards appearance, 26 concern with being overweight, 33 endorsement of makeup use, 25 investment in appearance, 33 mass media influence on body image, 33 physical comparison to others, 33 attitude towards favorite celebrities, 26 and vicarious experience of cosmetic surgery. 20 However, one study found a negative relationship between level of body satisfaction and acceptance of cosmetic surgical procedure. 26 A few studies analyzed factors associated with acceptance by gender identity. Men were found to be significantly more accepting of cosmetic surgical procedure for social reasons including relationship and career development when compared to women. 17 For men, the lower their BMI, the more accepting they were of cosmetic surgical procedure. 25 Conversely, women were found to be more accepting of cosmetic surgical procedure when they internalized societal standards of attractiveness, exhibited increased pursuit of materialistic goals, and reported having appearance-focused fathers. 24 Perception of Others Who Undergo Cosmetic Surgical Procedure, the Surgical Profession, and Representation of Cosmetic Surgical Procedure in the Media Three studies evaluated participants’ perceptions about individuals who had cosmetic surgical procedure, cosmetic surgery as a medical profession, and media sources about cosmetic surgical procedure. 20 , 21 , 29 , 35 Regarding perceptions about individuals who undergo cosmetic surgical procedure, participants viewed these individuals as materialistic, self-conscious, and perfectionistic. 20 In assessments of the cosmetic surgery profession, participants had lower confidence in people working in cosmetic surgery when compared to other medical professions. 29 Regarding cosmetic surgery media sources, Zhao 35 found that female college students perceived cosmetic surgery media sources to have little impact on themselves and stronger impact on other women to seek out invasive cosmetic surgical procedures. Additionally, another study found that increased exposure to cosmetic surgery advertising resulted in increased approval and confidence in people working in cosmetic surgical procedure. 29 Discussion Interest in cosmetic procedures has soared over the past two decades. The total value of the cosmetic procedure industry was estimated to be around $51 billion in 2018 with a projected average 3.6% compound annual growth rate through 2026. 36 Young adults are one of the fastest growing markets for injectables including neurotoxins and hyaluronic acid fillers. In one European market, the share of patients receiving injectables who were ages 18–25 increased from 2% in 2011 to 8% in 2017. 37 Additionally, this cohort represented over a quarter of cosmetic surgery cases in 2012. 38 These trends are evident in an environment of rapidly rising demand throughout the population and across national lines. 39 In light of these trends, it is critical to understand the factors underlying patient attitudes with regard to cosmetic surgical procedures in this cohort. Several studies included in this review compared demographic differences with regard to interest in cosmetic surgical procedures. Among the college-aged samples in the review, women tended to be more interested in cosmetic enhancements than men. 21 , 22 It is important to consider that many of the studies reviewed included only female cohorts. Other sources have indicated that interest in cosmetic surgical procedures among men has been steadily growing. 40 Patient race and ethnicity does not appear to consistently correlate with openness to cosmetic surgical procedures, although many of the studies likely lacked the diversity to accurately identify different statistical trends among races. Future research should consider the inclusion of more diverse samples, with respect to gender and race, in order to determine if any differences exist between groups. Openness to cosmetic surgical procedures is dependent upon a multitude of factors. Park and Cho 30 hypothesized that three key elements informed patient readiness to undergo cosmetic surgical procedures: interpersonal experiences, self-esteem, and media exposure. The attitudes of friends and family sway patient perception of cosmetic surgical procedures. Sarwer et al 33 found that over half of participants in a survey of female college students would be embarrassed to tell people other than family and close friends. In fact, data suggest that social acceptance and support may be one of the strongest predictors of likelihood for patients to undergo cosmetic surgical procedures. 13 Park and Cho observed that young adults with more interpersonal experiences with cosmetic surgical procedures, such as talking about procedures with friends, family, and acquaintances and knowing individuals who have undergone procedures, reduced the perceived risks and raised socio-cultural approval of elective cosmetic surgical procedures. 30 Body dissatisfaction is another known driver of consumption of aesthetic procedures. 39 Among college-aged adults in the United States, lower personal ratings of physical attractiveness are associated with increased likelihood of undergoing cosmetic surgical procedures. 12 , 39 Similarly, body satisfaction is inversely related to desire for cosmetic surgical procedures. 23 , 25–27 , 31 These findings mirror those identified in older cohorts. 41 Several studies identified psychiatric pathologies including body dysmorphia and eating disorders as significant predictors of likelihood to consider cosmetic surgical procedures among this cohort. 18 , 19 , 30 These results are unsurprising. Onset of anxiety and obsessive-compulsive spectrum disorders is common in young adulthood and likely the result of a complex interplay of biopsychosocial factors. 42 It is critical for clinicians to identify patients with body dysmorphia, since these patients have high rates of dissatisfaction with cosmetic surgical procedure outcomes. 43 Body satisfaction is largely a cultural phenomenon, and specific elements influencing patient body satisfaction are dependent upon the influence of regional societal factors. 44 Western ideals of beauty are based upon conceptions of proportion and symmetry found in nature. Feminine facial beauty has been numerically analyzed by measuring facial proportions of Caucasian celebrities and models. Classically, the face is divided into thirds, and within each third are ideal ratios of facial features. 45 Male faces with masculinized features including wide-set jaws, prominent cheekbones, and highbrow ridges were rated as most attractive 46 by women. Similar anthropometric analyses of female digital silhouettes have been used to calculate the idealized proportions of waist-to-hip ratio, where the ideal hourglass figure regarding waist-to-hip ratio for females was found to be 0.7. 47 Recent data suggest that the idealized body composition among women may be lower than the healthy BMI. 48 These standards have been criticized for being Eurocentric and heteronormative in nature but likely influenced the participants investigated by the studies included in this review. 49 In the twenty-first century, media has played an increasing role in shaping societal beauty standards. Markey and Markey 27 used the Sociocultural Attitudes Toward Appearance Questionnaire (SATAQ) to evaluate the role of television and magazines on self-perception of beauty. They found that young women who are more influenced by media messages are more likely to be dissatisfied with their bodies. Many of the studies in this review specifically examined the role of media in approval of cosmetic surgical procedures among young adults. Delinsky 20 found that most participants reported watching television programs about cosmetic surgery, and approval of cosmetic procedures increased with increasing media exposure. Sperry et al 34 further clarified that viewership cosmetic reality shows specifically correlated to perceived safety and actual history of undergoing cosmetic procedures. Park and Allgayer 29 found that cosmetic surgery advertising exposure resulted in higher perceived social benefits of cosmetic procedures. Zhao 35 broadly assessed the effect of media exposure on intentions of young women in the United States to undergo cosmetic surgical procedures and found that increasing total media consumption correlated to increasing intentions to undergo cosmetic surgical procedures. This study included television, magazine, newspaper, radio, Internet, and social media to form a composite score reflecting total media exposure and its effect on intentions in this cohort. 35 The emergence of social media introduced a new dimension of media influence, especially for young adults. As the most avid consumers of social media, young adults are especially susceptible to aesthetic trends. Industry research has demonstrated that US adults aged 18–29 prefer more visually orientated social media platforms including Instagram, Tik Tok, and Snapchat rather than more text-based platforms such as Facebook and Twitter. 50 The effect of social media on intentions and body satisfaction has been highlighted recently, with data suggesting that more social media use is associated with greater body dissatisfaction and greater intentions to undergo cosmetic surgical procedures. 51 Not only does social media offer opportunities for consumption of direct and indirect consumer advertising but it also increases user’s exposure to self-images. A study of 400 university students in 2017 found that more than half took one or more “selfie” style images per day. 52 Every self-image is a chance to examine one’s facial features, and more scrutiny is sure to reveal more imperfection. Gillen and Markey 23 examined this phenomenon in 2020 and noted that women with more “body surveillance” were significantly more interested in pursuing cosmetic surgery. Body surveillance and assessment of self-images dramatically increased during the COVID-19 pandemic as most of the world economy was digitalized. The use of online conference software increased exposure to self-images. Some authors have labeled this phenomenon “Zoom Dysmorphia” and suggested that the move to video chat platforms increased the amount of time patients study their faces. 53 Increased body surveillance via video chat platforms may have contributed to the so-called “Zoom Boom” for the cosmetics industry with an estimated 10–20% increase in procedure volume in Western markets despite cessation of services for several months. 54 Limitations Several limitations should be acknowledged when interpreting the findings from this narrative review. Among the studies included in the review, the samples were predominantly female and white, limiting the generalizability of the findings from the review to other gender and racial identities. Further, the sample sizes among the reviewed studies varied, with some studies containing small sample sizes. The sample size differences in the reviewed studies limit the ability to draw conclusions from the findings across studies. The review intended to assess cosmetic surgery attitude, acceptance, interest, perceptions, and beliefs. Operationalization of these variables was not consistent across the reviewed studies, which limits the ability to compare findings across multiple studies. The review was also restricted to three databases (ie, PubMed, NCBI, ScienceDirect), which may have inadvertently excluded studies from the review. However, to ensure all qualifying studies were included, the authors utilized a comprehensive list of search terms, did not restrict studies by date of publication, and cross-referenced Google Scholar to search for additional studies. Finally, although the review is comprehensive, only cross-sectional research studies were included, limiting any determination of causation from the findings in the review. Conclusions Pursuit of surgical and nonsurgical cosmetic surgical procedures has increased among adults, including college-age young adults in the United States. Demographic, intrapersonal, interpersonal and societal factors all play a role in pursuing cosmetic surgical procedures among this group of individuals, including factors related gender, self-perception, body weight, and the media. In general, heightened awareness of and dissatisfaction with one’s self-image appears correlated with pursuit, positive attitudes, and acceptance of cosmetic surgery. Despite the demand for cosmetic surgery, negative perceptions remain of individuals who undergo cosmetic surgery and of the cosmetic surgical profession. Future studies will be required to identify factors related to pursuit of surgical versus minimally invasive cosmetic surgical procedures and the targeting of specific anatomic areas among young adults in the United States. Funding