For the hypothesized path model, the hypothesis that self-assessment is a mediator of the effect of self-esteem and self-efficacy on the decision for cosmetic surgery was rejected because of poor model fit. For the final path model, the model with good-fit coefficients reveals that self-esteem and self-efficacy mediate the negative effect of self-assessment on the decision for cosmetic surgery. For the path model for psychotherapeutic effect of cosmetic surgery, the model indicates that young women undergoing facial cosmetic surgery tend to develop enhanced self-esteem and self-efficacy in our cohort. β Values refer to standardized direct effects on the downstream variables, and the R value refers to the correlation coefficient. The solid lines with single arrow represent significant parameter estimates, the solid line with double arrows represents statistical correlation, and the dotted lines represent nonsignificant parameter estimates. Marital status is coded as 1 for married, 2 for unmarried partner, and 3 for single. Error variances and covariances are not shown.
aP < .05.
bP < .01.
eFigure 1. A Representative Standardized Face Image
eFigure 2. A Representative Part of the Internet-Based Objective Assessment Questionnaire
eMethods. Chinese- and English-Version Instruments for Measurement of Self-esteem, Self-efficacy, and Self-assessment of Facial Appearance
eTable. Demographic Characteristics of the Study Groups
Yin Z, Wang D, Ma Y, Hao S, Ren H, Zhang T, Chen W, Fan J. Self-esteem, Self-efficacy, and Appearance Assessment of Young Female Patients Undergoing Facial Cosmetic Surgery A Comparative Study of the Chinese Population. JAMA Facial Plast Surg. 2016;18(1):20-26. doi:10.1001/jamafacial.2015.1381
The psychological traits of cosmetic surgery patients (CSP) are important for selecting patients and postoperative patient satisfaction. A patient’s self-esteem, self-efficacy, and self-assessment affect his or her motivation for cosmetic surgery, but the association among these traits remains unclear, especially in the Asian population.
To clarify the association of a patient’s psychological traits, decision to undergo cosmetic surgery, and the effectiveness of facial cosmetic surgery on the psychological conditions of young, female Chinese patients.
Design, Setting, and Participants
Three different groups of young women (aged 18-30 years) from the Plastic Surgery Hospital, Chinese Academy of Medical Sciences, and 7 universities were enrolled from January 1, 2012, through December 31, 2014: CSPs (n = 161), general population controls (GPCs) (n = 355), and facial appearance raters (FARs) (n = 268). The last date of follow-up was January 20, 2015. Patient data from questionnaires were obtained preoperatively and 6 months postoperatively, and the data from the control groups were obtained immediately after enrollment. Front-view facial images of the study participants were taken and then shown to independent raters to assess the participants’ facial appearances on a rating scale.
Main Outcomes and Measures
Evaluation of self-esteem and self-efficacy, subjective and objective assessment of facial appearance, and structural equation models.
A total of 163 CSPs and 387 GPCs were recruited for the study, and complete and valid data were obtained from 161 CSPs and 355 GPCs. All responses from the 268 FARs met the criteria for subsequent analysis. Of the questionnaires issued to the CSPs 6 months postoperatively, 126 valid responses were returned (response rate, 78.3%). Self-esteem and self-efficacy decreased significantly in preoperative patients compared with controls (P < .001) (mean [SD] scores, 22.60 [1.80] for CSPs and 27.39 [2.11] for GPCs for self-esteem and 21.50 [2.40] for CSPs and 28.59 [4.23] for GPCs for self-efficacy) and were found to be at nearly normal levels 6 months postoperatively (mean [SD] scores, 25.88 [3.65] and 26.38 [2.45] for self-esteem and self-efficacy, respectively). The patients’ objective assessments of facial appearance did not differ significantly from those of the control group participants (mean [SD] scores, 4.51 [0.77] and 4.55 [0.74] for CSPs and GPCs, respectively; P = .86); however, a significant decrease in patient self-assessment was noted (mean [SD scores], 6.45 [1.15] and 7.31 [1.42] for CSPs and GPCs, respectively; P = .01). Moreover, the structural equation models revealed a path from low self-esteem and self-efficacy after decreased self-assessment to decision for cosmetic surgery.
Conclusions and Relevance
Self-esteem and self-efficacy mediate the negative effects of self-assessment on the decision of young women to undergo facial cosmetic surgery. The impairment of self-esteem and self-efficacy may indicate the need for preoperative psychological intervention. Facial cosmetic surgery can have positive effects on self-esteem and self-efficacy.
Level of Evidence
During the past decade, the number of patients undergoing facial cosmetic surgery in China has markedly increased. According to the International Society of Aesthetic Plastic Surgery survey,1 China has been ranked in the world’s top 3 countries for number of citizens having undergone facial cosmetic surgery. As more young women seek to improve their physical appearance through plastic surgery and this practice becomes more widely embraced and accepted by society, more research is being dedicated to investigating the psychosocial profiles of female patients undergoing cosmetic surgery and the psychotherapeutic effects of cosmetic surgery.2,3
Most previous studies4- 7 have focused on patients’ negative body image or self-assessment of facial appearance, which has been proposed as the main psychological cause of the decision to undergo cosmetic surgery. However, because the psychological reasons for undergoing cosmetic surgery are multifactorial, the effect of other variables associated with the decision process, such as self-esteem and self-efficacy, should be taken into consideration when investigating the motivation for undergoing cosmetic surgery. Unfortunately, the causal relationship between these potential variables and the decision to undergo cosmetic surgery remains unclear, especially when the difference of objective assessment of facial appearance is taken into account. Moreover, insufficient data have been published concerning the psychological assessments of Chinese patients undergoing cosmetic surgery. Such data are greatly needed for patient screening and treatment individualization.
In this study, we applied a prospective, comparative design to examine these psychosocial traits with respect to facial cosmetic surgery and the effectiveness of cosmetic procedures as a psychological intervention in young, female Chinese patients. Structural equation models (SEMs) were used to further confirm the reciprocal causality between psychological variables and cosmetic surgery.
Three different groups of participants were enrolled from January 1, 2012, through December 31, 2014: cosmetic surgery patients (CSPs), general population controls (GPCs), and facial appearance raters (FARs). Measurements were taken immediately after the enrollment of the study participants. Statistical analysis was performed from March 1 through March 31, 2015. The last date of follow-up was January 20, 2015. The ethics committee of Plastic Surgery Hospital, Chinese Academy of Medical Sciences, approved the study, and written informed consent was obtained for all participants.
The CSP group consisted of 163 female patients who had decided to undergo cosmetic blepharoplasty or rhinoplasty in the Plastic Surgery Hospital. Patients aged 18 through 30 years who requested surgery primarily for cosmetic reasons were considered eligible for the study. The GPCs were 387 female volunteers who had never visited a plastic surgeon before. They were randomly recruited from 5 universities in Beijing and were Han Chinese with Han Chinese parents. They were also 18 through 30 years old. Potential CSPs and GPCs were excluded if they had ever been diagnosed as having a mental disorder, had conspicuous scars or defects in physical appearance, or had ever been treated for a facial aesthetic concern.
The demographic characteristics of the CSPs and GPCs, including age, educational level, occupation, and marital status, were obtained. The day before surgery, the CSPs received a 34-item questionnaire on self-esteem, self-efficacy, and self-assessment of facial appearance. The completed questionnaires were returned on the day of surgery. Six months after surgery, a 20-item questionnaire on self-esteem and self-efficacy was sent by email to the CSPs, and questionnaires were collected 2 weeks later. The GPCs were asked to complete the same 34-item questionnaire as stated above. All surveys were anonymous, and no personal identifying data were recorded.
Front-view facial images of preoperative CSPs and GPCs were taken according to the requirements in the previous literature.8 A Panasonic GF-1 digital camera with a prime lens with a 40-mm equivalent focal length (Panasonic Corp) was used to take the images. All facial images were processed by Adobe Photoshop CS6 (Adobe Systems Inc) to eliminate the visibility of the hair and ears but to leave the images of the face and part of the neck intact; a blue background was used so as not to distract from the facial images (eFigure 1 in the Supplement). These standardized facial images were placed in an Internet-based questionnaire to be administered to the FAR group for objective assessment of facial appearance.
Next, 268 candidates were recruited as FARs from 2 other universities. Han Chinese students with Han Chinese parents 18 through 30 years old were eligible for the study. No sex restrictions or further exclusion criteria were arranged for the FAR group. The demographic characteristics, including sex, age, and educational level, were obtained. Written informed consent and confidentiality agreement forms were signed before the Internet-based questionnaire (eFigure 2 in the Supplement) was issued. The completed questionnaires were collected automatically.
The Chinese version of the Rosenberg Self-Esteem Scale (eMethods in the Supplement), the most widely used instrument, was used to assess self-esteem.9,10 It is composed of 10 items designed on a 4-point Likert scale ranging from “strongly agree” to “strongly disagree,” with raw scores ranging from 10 to 40. A higher score indicates a higher level of self-esteem. The scale has been confirmed as a reliable and valid quantitative tool for the assessment of self-esteem in CSPs.11- 13
The Chinese version of the General Self-Efficacy Scale (eMethods in the Supplement) was used to assess self-efficacy.14,15 It contains 10 questions, and scores range from 10 to 40; the higher the score, the higher the efficacy of the individual. The scale has been used with certified stability in CSPs.16
Two questionnaires on facial appearance assessment (self-assessment and objective assessment) were designed for our study (eMethods in the Supplement). The self-assessment questionnaire was issued to CSPs and GPCs to measure the self-evaluation of hair, forehead, eyebrows, eyes, ears, nose, lips, teeth, chin, cheek, face shape, facial skin quality, and overall facial appearance. The objective assessment questionnaire was designed for FARs to independently evaluate the facial attractiveness of the eyebrows, eyes, nose, lips, chin, cheek, and overall facial appearance of the CSPs and GPCs. In both questionnaires, the respondents rated the items from 0 to 10 using 1-point increments (0 indicating extremely unattractive and 10 indicating extremely attractive). To avoid measurement bias, it was stipulated that the FARs should assess the faces according to their primary impressions and should leave the section of questionnaire empty if he or she recognized the face on the screen.
Continuous variables were compared by 1-way analysis of variance or the t test, and the Pearson χ2 test was applied to determine discrete variable comparison using SPSS statistical software, version 20.0 (SPSS Inc). Pearson and Spearman rank correlation analyses were performed on demographic and psychological variables. Path analysis using SPSS Amos, version 21.0, was performed to establish the SEMs. The model fit was tested based on the following rules17: (1) χ2 value: a lower χ2 value and a nonsignificant P value (P > .05) indicate an improved model fit; (2) the root mean square error of approximation (RMSEA): best if below 0.05; and (3) the comparative fit index (CFI): best if above 0.95. Significance was assumed at P < .05 for all analyses.
A total of 163 CSPs and 387 GPCs were recruited for the study, and complete and valid data were obtained from 161 CSPs and 355 GPCs. All responses from the 268 FARs met the criteria for subsequent analysis. Of the questionnaires issued to the CSPs 6 months postoperatively, 126 valid responses were returned (response rate, 77.3%).
All participants were Han Chinese, and the groups were well balanced in terms of age and marital status (eTable in the Supplement, P = .32). As indicated in the eTable in the Supplement, significant differences were revealed with respect to educational level and occupation (P = .22). More CSPs had lower educational levels (bachelor’s degree or below) than GPCs and FARs (128 of 161 [79.5%], 210 of 355 [59.2%], and 168 of 268 [62.7%], respectively). As for occupation, most CSPs were employed (105 of 161 [65.2%]), whereas most GPCs were students (278 of 355 [78.3%]). Regarding the surgical choice of the CSPs, 64 patients (39.7%) underwent cosmetic blepharoplasty, 84 (52.2%) sought cosmetic rhinoplasty, and 13 (8.1%) chose both procedures.
As indicated in Table 1, significant differences (P < .001) were found in the scores on the Rosenberg Self-Esteem Scale and the General Self-Efficacy Scale by means of 1-way analysis of variance. The Bonferroni post hoc analysis was subsequently performed for further comparison between any 2 of the 3 groups. Mild to moderate impairments of self-esteem and self-efficacy were found significantly in the preoperative CSPs compared with the GPCs (P < .001). A meaningful increase in self-esteem (P = .02) and self-efficacy (P = .046) of CSPs was observed 6 months after surgery. Meanwhile, differences between the scores of postoperative CSPs and GPCs did not approach statistical significance for self-esteem (P = .26) or self-efficacy (P = .42).
According to previous reports,8,18,19 judgment of facial appearance from a third-party perspective can be considered an objective assessment. Therefore, in our study, we used a 7-item questionnaire for the objective assessment of facial appearance and a 13-item self-assessment questionnaire. The objective and subjective scales revealed good internal consistency with a Cronbach α of 0.965 and 0.882, respectively. The results of the survey, which were in line with our hypothesis, indicate no significant difference in objective assessment of facial appearance between the CSPs and GPCs (Table 2, P = .86). On the other hand, the mean scores of the CSP self-assessment of the eyes (P = .02), nose (P < .001), and overall facial appearance (P = .01) were significantly lower than the ratings of the GPC group (Table 2). The intragroup comparison noted that the self-assessment scores were significantly higher (P < .001 for all) than the objective ratings in all 7 items of the GPC group and in 5 items of the CSP group (Table 3). These results are consistent with a previous non-Chinese study.20 The eyes and nose were exceptions, and this finding suggests a specific self-assessment impairment in the CSP group.
We next detected correlations among the variables to select coefficients for SEM establishment (Table 4). All psychological variables that were significantly correlated to each other were considered for the following investigation. Marital status was also involved because of its significant correlation to self-assessment and self-efficacy. To further explore the causal relationship between the underlying variables and facial cosmetic surgery, path analysis was conducted, and 3 SEMs (Figure) were established according to the hypotheses in previous literature.21,22 The first model assumed that self-assessment may be a mediator of the effects of self-esteem and self-efficacy on the decision to undergo cosmetic surgery. However, this model was rejected because of a poor fit (χ2 = 43.635, P < .001; RMSEA, 0.20; 90% CI, 0.15-0.26; CFI, 0.37). Thus, a theoretically and statistically more sound model with a good fit was developed (χ2 = 3.486, P = .32; RMSEA, 0.03; 90% CI, 0.00-0.10; CFI, 0.99). This model indicates that a young female patient with a lower self-assessment of her facial appearance is more likely to possess lower self-esteem (β = .18, P = .04) and self-efficacy (β = .37, P = .004) and is therefore more likely to seek cosmetic surgery (β = –.54 and β = –.26 and P = .004 and P = .001, respectively). In return, as shown in the third model (χ2 = 1.254, P = .26), patients undergoing cosmetic surgery tend to develop enhanced self-esteem (β = .52, P = .02) and self-efficacy (β = .73, P < .001). In the second model, marriage was found to exert a significantly positive effect on self-assessment (β = –.23, P < .001) and self-efficacy (β = –.23, P = .048).
The psychometric evaluation of patients undergoing cosmetic surgery and the psychological effect of cosmetic procedures are always of considerable interest to plastic surgeons for the purpose of selecting patients and improving postoperative patient satisfaction. The prevalence of this issue can be attributed to an incomplete understanding of the psychological indications for cosmetic surgery. Previous literature2,3,21,23 has reported a variety of psychosocial traits that may influence the motivation for cosmetic surgery and are significantly improved postoperatively. However, the causal relationship between these variables and cosmetic surgery remains largely unknown, and the results are not conclusive for the Chinese population because of cultural and racial differences. To our knowledge, our research is the first prospective, comparative cohort study of the Chinese population that examines the differences and associations among the psychological variables of patients and the general population. In addition, the causality between candidate variables and facial cosmetic surgery was investigated and illustrated by the SEMs.
Self-esteem reflects an individual’s holistic evaluation of his or her own worth, and general self-efficacy refers to the belief of being competent enough to cope with the challenges of life and work. Both psychological traits have been reported as components of core self-evaluation,24 which predicts life satisfaction and subjective well-being.25,26 Lower self-esteem and self-efficacy prompt people to seek cosmetic procedures.16,27,28 Our investigation also presents similar results among the Chinese population by comparison of CSPs and GPCs. In line with previous studies,29,30 6 months after facial cosmetic surgery, patients’ self-esteem and self-efficacy levels improved meaningfully, and no significant differences were found when compared with the GPCs. These findings suggest a positive psychotherapeutic effect of cosmetic surgery.
Self-assessment of facial appearance, which reflects an individual’s appraisal of his or her own face, has been proposed as another predictor for the reason why people choose to undergo cosmetic surgery.22,31 In our study, the facial appearance self-assessments of CSPs and GPCs were compared with the objective assessments of the facial images of the same individuals. The results revealed no significant difference in the objective assessment between CSPs and GPCs, indicating that an objective third-party assessment may not explain the decision for cosmetic surgery. On the other hand, the significant distinction in self-assessment of overall facial appearance between CSPs and GPCs supports the assumption that young women with lower self-assessed attractiveness are more likely to pursue facial cosmetic procedures. According to the face recognition theory,32 a 2-order model of face image processing has been substantiated with the first-order and second-order information characterizing the morphologic features of discrete facial regions and the configural face appearance, respectively. The discrepancy of the first-order information (self-assessment of eyes and nose) between the CSPs and GPCs corresponds to the major concerns of the CSPs, causing them to undergo blepharoplasty and/or rhinoplasty. On the other hand, the distinction in the second-order information (self-assessment of overall facial appearance) suggests that other psychological variables may influence or mediate the lowering of the patients’ self-assessment.
Plastic surgeons have previously recognized that operating on a psychologically abnormal patient may result in a great mental burden to the patient as well as subsequent impairment to satisfaction with the surgical outcome.2 Therefore, it is necessary to clarify the direct or indirect properties of each possible psychological variable in the decision for undergoing cosmetic surgery. In our study, the SEM was applied to quantify the causal relationship between psychological variables and facial cosmetic surgery in the Chinese population. Self-esteem, self-efficacy, self-assessment, and marital status were candidate variables in the hypothesized SEMs. The final model implies that self-esteem and self-efficacy heighten the effects of a negative self-assessment of facial appearance in the decision to undergo surgery. This model is in line with previous Norwegian studies11,21 that found that cosmetic surgery is less attractive to young women who are already married, most likely because fewer social or marital advantages can be obtained through invasive procedures. In addition, our findings support the results of a functional magnetic resonance imaging essay by Oikawa et al,33 which found that the specific brain regions positively correlated with self-esteem can be activated by self-assessment of facial appearance. Furthermore, as speculated, a strong correlation was revealed between self-esteem and self-efficacy, supporting their synergistic mediating effects in the model. Therefore, it is self-esteem and self-efficacy rather than self-assessment that directly affect patients’ decisions for undergoing cosmetic procedures. We believe that when the degree of self-esteem and self-efficacy impairment secondary to decreased self-assessment of facial appearance is out of proportion, plastic surgeons need to involve psychiatrists in the patient’s care before surgery to avoid the risk of unnecessary dissatisfaction.
The psychotherapeutic effect of cosmetic surgery has been discussed by a variety of studies.3,34 Nevertheless, we are the first, to our knowledge, to confirm the effectiveness of facial cosmetic procedures using causality analysis by an SEM in a prospective cohort study. Outcome research5 suggests that patients with body dysmorphic disorder traits typically do not benefit from surgical treatment. However, unlike body dysmorphic disorder, impaired self-esteem and self-efficacy were found to be at a nearly normal level postoperatively in our cohort.
The current study has several limitations. First, because the CSPs who decided to undergo cosmetic blepharoplasty and/or rhinoplasty were enrolled in a national center for plastic surgery, results may not be generalizable to all patients undergoing facial cosmetic surgery. Furthermore, our reliance on university students in Beijing for GPC and FAR recruitment also blunts the generalizability of our findings to all community residents in China. Second, although more than 500 patients and controls and 268 raters participated in our survey, the sample size of the analyses may be not sufficient to ensure the statistical significance level. Third, 6 months is the shortest acceptable follow-up period for therapeutic research in cosmetic surgery, which may be not adequate for a conclusive comment. Fourth, only 78.3% of postoperative CSPs responded to the emailed follow-up questionnaire, which may have led to selection bias because the patients with unchanged or decreased self-esteem and self-efficacy may have been missed. Moreover, we allowed up to 10% missing data, which may also have affected the results.
The main strength of the present study is the comparison of self-assessment with objective assessment and the validated SEMs illustrating the causality between psychological variables and cosmetic surgery in a Chinese population. Our study indicates that self-esteem and self-efficacy mediate the negative effect of self-assessment on the decision of young women to undergo facial cosmetic surgery. In return, cosmetic surgery exerted therapeutic effects on self-esteem and self-efficacy impairment in our cohort. However, more research is needed to screen additional variables by path analysis so as to clarify the indication of patients pursuing cosmetic surgery for psychotherapy.
Accepted for Publication: August 12, 2015.
Corresponding Author: Jincai Fan, MD, Ninth Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 33, Ba Da Chu Road, Shijingshan District, Beijing 100144, China (firstname.lastname@example.org).
Published Online: October 15, 2015. doi:10.1001/jamafacial.2015.1381.
Author Contributions: Drs Yin and Fan had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Yin, Hao, Fan.
Acquisition, analysis, or interpretation of data: Yin, Wang, Ma, Hao, Ren, Zhang, Chen.
Drafting of the manuscript: Yin, Ren.
Critical revision of the manuscript for important intellectual content: Wang, Ma, Hao, Zhang, Chen, Fan.
Statistical analysis: Yin, Ma, Zhang.
Obtained funding: Yin, Fan.
Administrative, technical, or material support: Wang, Ma, Hao, Ren, Chen.
Study supervision: Fan.
Conflict of Interest Disclosures: None reported.
Funding/Support: This work was supported by grant 2013-1002-12 from the Doctorial Innovation Fund of Peking Union Medical College (Dr Yin).
Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication.
Additional Contributions: The student unions and graduate student associations of Peking Union Medical College, Peking University, Peking University Health Science Center, Beijing Normal University, University of Science and Technology Beijing, China Women’s University, and Capital Normal University assisted with participant recruitment and questionnaire distribution and collection.