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1.
My body is sexually appealing.
2.
I like my looks just the way they are.
3.
Most people would consider me good-looking.
4.
I like the way I look without my clothes on.
5.
I like the way my clothes fit me.
6.
I dislike my physique.
7.
I am physically unattractive.
Factor subscales used for MBSRQ include the following [61]:
Appearance Evaluation: Personal feelings about physical attractiveness based on
satisfaction of personal look.
Appearance Orientation: Personal view of how much physical appearance cared and the
extent of investment in one’s appearance.
Fitness Evaluation: Personal view of whether the person is physically fit or not.
Fitness Orientation: Time and energy spent on attempting to be a physically fit or
athletically competent person.
Health Evaluation: Perception of one’s own physical health dependence of physical
illness.
Health Orientation: Level of investment on having a physically healthy lifestyle.
Illness Orientation: Extent of reactivity to being or becoming ill.
Body Areas Satisfaction Scale: Covers discrete aspects of one’s appearance that is not
covered in the Appearance Evaluation subscale.
Overweight Preoccupation: This scale assesses a construct reflecting fat anxiety, weight
vigilance, dieting, and eating restraint.
Self-Classified Weight: Self-perception of weight scale labeling from very underweight to
very overweight.
What follows next is the coverage of factors that relate to facial plastic surgeries that
include self-esteem, teasing, education level, culture, media, social media, and technology.
3.2 Self-Esteem Measurements
Self-esteem is observed to improve plastic surgery patients in limited number of research.
One common scale used for measuring self-esteem is the Rosenberg questionnaire
classification. The questionnaire prepared by Rosenberg [76] was originally designed to
measure the self-esteem of high school students, and it has been used with a variety of
groups including adults, with norms available for many of those groups. The 4-point scale
used for the analysis is the following:
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1=Strongly agree 2=Agree 3=Disagree 4=Strongly disagree.
The following questionnaire is used for Rosenberg self-esteem scaling (RSE) [62]:
1.
On the whole, I am satisfied with myself.
2.
At times I think I am no good at all.
3.
I feel that I have a number of good qualities.
4.
I am able to do things as well as most other people.
5.
I feel I do not have much to be proud of.
6.
I certainly feel useless at times.
7.
I feel that I’m a person of worth.
8.
I wish I could have more respect for myself.
9.
All in all, I am inclined to think that I am a failure.
10.
I take a positive attitude toward myself.
Multidimensional Self-Concept Scale introduced in [64] is another commonly used
method for scaling self-esteem of persons. As the title of the scale contains, this
multidimensional scale is composed of 150 items with four alternative answers for each one
using the scale of absolutely true, true, not true, and absolutely not true [14].
It has been observed in the literature that personal appearance and self-esteem are
strongly correlated [15]. The researchers conclude that patients expecting positive feedback
from the surgery, in turn, increase their self-esteem [14]. As covered in Sect. 2, facial plastic
surgery numbers are increasing over the years with the age of patients undertaking the
surgery getting younger and younger. Cosmetic plastic surgeries on youth are likely to
cause changes that alter the natural structure of both physical and psychological changes
that occur naturally, noting that the physical and psychological development starts early
during the childhood [67]. The encouragement of parents, relatives, and loved ones towards
facial plastic surgery by giving it as a gift can also impact the decisions of those who may
not even consider plastic surgeries.
3.3 Teasing
There are mixed results attained in the research literature for the impact of teasing on
cosmetic plastic surgery decisions; The psychological impact of childhood experiences with
others may or may not impacts one’s decisions on undertaking cosmetic plastic surgery. No
correlation between the two are observed in [65], while the contrary is observed in [15].
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Adolescents seeking cosmetic surgery could be associated with being teased or
attempting to gain social acceptance from others. Adolescents are observed to benefit from
cosmetic procedures in [66] based on the research conducted on the postoperative responses
of 86 participants. Majority of these participants reported satisfaction with their life, body
image, and self-esteem, with positive feedback from people surrounding them. Majority of
these participants reported an increase in their self-confidences and self-esteems, improved
moods, and felt better their physical appearances. An impact of the surgery on social
interactions of these persons with their improved ability to make friends and increase
popularity. From a research standpoint, we recommend asking and answering the following
question:
Is the physical appearance causing an unnecessary mental barrier in one’s mind to be
social, make friends, and be popular?
Even though we don’t seek an answer to this question, we hypothesize that the physical
appearance causes an unnecessary mental barrier in one’s mind to be social, make friends,
and be popular. The response to the abovementioned question relates to the power of mind
and mental construction of a person to be popular or make friends.
3.4 Education and Culture
Education and culture are factors that may be impacting the facial plastic surgery decisions;
however, there has not been extensive research conducted in this area of interest.
Historically, back in 2006, there was an increase of 444% in the number of cosmetic
surgical procedures. General statistics indicate that the majority of plastic surgery patients
are Caucasians [1].
There is limited research on investigating the correlation between educational level and
facial plastic surgery decision. It is reported in [16] that 24-year-old females with a
university degree and economical strength to cover expenses are the typical plastic surgery
patients. In addition, about 23% of plastic surgery patients are reported to have high school
education, while 73% is reported to have a university education.
3.5 Impact of Media and Technology
Top 10 emerging technologies in the years 2018 and 2019 included 5G networks’ rise and
rapid progress of smart phone technologies. The ability to store large data (such as videos)
and share them through the advancement of internet made it easy to access data worldwide.
The impact of social media through friends, families, and popular artists started to impact
anyone who had access to a smartphone; ability to access data worldwide started to rise and
view of such data became inevitable unless self-control is established. Photo editing apps
used as cellular phone applications started to become popular for individuals to view or
present themselves in different appearances through manipulation of images. Prolonged
engagement with social media and smartphone screen time is determined to associate with
poorer academic performance, decrements in body image and self-esteem, depressive traits,
and eating disorders in young women [69–75]. Media such as magazines, television, and
music along with social media such as Tweeter, Facebook, etc. have a strong coverage of
the world’s population with its psychological impact on those persons following these
channels. To the best of our knowledge, there has not been an extensive study to determine
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the psychological impact of media and social media on the facial plastic surgery (or general
plastic surgery) decisions. We invite researchers to investigate furthermore in this area of
interest.
4 Positive Outcomes of Facial Plastic Surgeries
There have been several facial plastic surgeries’ positive outcomes reported in the research
literature. Rhinoplasty is one of the surgical procedures for which patients’ physical and
psychological well-being is investigated most extensively. Postoperative 1- and 16-week
follow-ups of 53 rhinoplasty patients are determined to have significant improvements in
self-regard and value of existence in [9, 77]. Total 24 cosmetic rhinoplasty and 24
functional rhinoplasty patients’ results are compared in [79] by using RSE, with significant
self-esteem improvement seen for only cosmetic rhinoplasty patients upon 6-month followups. MBSRQ and Rhinoplasty Outcomes Evaluation Questionnaire are used in [78], with a
significant improvement observed in body image of the patients after 1year. Personality
and Anxiety Testing are used in [8] to investigate 79 rhinoplasty patients’ postsurgical
improvements, and a significant reduction in anxiety is observed during 6- to 60-month
follow-ups postoperatively. A significant improvement on the appearance of the nose,
nostrils, and the face is seen on 23 rhinoplasty patients in [5] by using Face-Q scale. A
decrease in discomfort and anxiety in 255 rhinoplasty patients is observed postoperatively
by using the European Quality of Life Questionnaire in [81] upon 12- to 48-month followups.
Blepharoplasty is another surgical procedure for which patients’ physical and
psychological well-being is investigated. Significant improvement in the self-esteem of 50
lower blepharoplasty patients are identified in [78] upon 6-month follow-ups by using RSE.
No significant changes in self-esteem of 60 upper blepharoplasty patients is identified in
[80] by collecting 3-month postoperative RSE data. Significant improvements in body
image of 60 upper blepharoplasty patients is detected in [7] upon 3-month follow-ups by
using body image questionnaire.
The last surgical procedure that we will cover is maxillofacial surgery with only one
study we determined in the literature. Significant improvements in self-esteem of 46
maxillofacial patients is observed in [7] by using Self-Esteem Inventory (Coopersmith) [4]
self-report questionnaire upon 4-month follow-ups.
Cognitive behavioral therapy, acceptance and commitment therapy, and social skills
training approaches are used for treatment of facial palsy patients in [6]. Individuals with
FP report difficulties accessing specialist psychological treatment due to lacking
psychological interventions tailored specifically for this population. Effectiveness,
acceptability, and feasibility of the designed therapy is evaluated in this pilot study. Pre- and
posttreatment data from participants is collected by using self-report measures assessing
psychological well-being, social function, and appearance-related distresses. Significant
improvements in psychological well-being and social functioning of patients are reported
by the authors. In addition, improvements in appearance-related distress are also observed.
About 80% of the participants reported feeling more able to cope with FP. It is concluded
by the authors that self-guided information and therapy guides are effective for improving
the psychosocial well-being of people with FP [6].
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5 Negative Outcomes of Facial Plastic Surgeries
There have been several negative factors that relate to facial plastic surgical procedures.
The impact of Covid-19 pandemic is investigated in [2]. The authors collected data from
patients in the United States and the United Kingdom. Due to the pandemic, the number of
requests for teleconsultations with plastic surgeons in private practice increased by 64% in
the United States. Patients received online consultation for plastic surgery via Zoom, and
they were inclined to undergo cosmetic surgery during the pandemic, 61% stating the
“lockdown face” while 36% mentioned the benefit of recovery during smart working from
home. The authors concluded from the overall data analysis that a patient’s negative selfperception is likely to be linked to the psychological impact of the pandemic on mood level
while video conferencing appeared to play a key role in rising requests for cosmetic surgery
consultations [2].
Psychological well-being of cosmetic surgery patients is investigated in [3] for
understanding the surgery’s impact on patients’ overall psychological health. The factors
are analyzed by using well-known tests such as MBSRQ and RSE to calculate personal
opinions on physical appearance, self-esteem, anxiety, and depression scores. Overall, the
review of the articles indicated that cosmetic surgery improves body image but remains in
disagreement on its effects on the following three important factors that play a significant
role in one’s life:
Self-esteem.
Anxiety.
Depression.
The next section is devoted to possible psychological factors that may impact facial
plastic surgery patients’ well-being. These factors are used in measuring TKA surgery
patients’ postoperative well-being but not emphasized strongly for facial plastic surgery
patients to the best of our knowledge.
6 Possible Psychological Factors that Impact Facial Plastic
Surgery Patients
Total knee arthroplasty (TKA) patients’ maximization of postoperative well-being have
been studied in the literature to optimize the associated outcomes. Research conducted on
TKA patients’ satisfaction rate based on their postoperative stress levels indicated a
minimum of 80% stress-free patient rate while the rest of the patients were distressed.
Noting the similar dissatisfaction levels of TKA patients and facial plastic surgery patients,
it may be possible to transform similar techniques to facial plastic surgery patients to be
explained in this section even before undertaking these surgeries.
For TKA patients, the factors of dissatisfaction included, but were not limited to, knee
functioning, pain relief expectations, artificial feeling of the prosthesis, and unmet
expectations of the patient [26–29]. Surgical outcome dissatisfaction [30] and functional
recovery [29] are observed to be the major reasons for the negative mental health states.
Patient reported outcomes is important for observing the overall success of the TKA
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procedures and maximization of patient satisfaction. Psychological factors that are observed
in the literature playing the key role in the improvements of patients’ TKA experience are
the following:
Self-efficacy.
In-hospital positive affect.
Postoperative vitality.
Vigor.
Studying the strategies and characteristics of the TKA operated patients that had
resilience against the negative factors have been the focus of recent research to be able to
understand and adapt those strategies to patients experiencing problems such as
dissatisfaction and distress [26]. Patients that had stronger preoperative mental and physical
strength are observed to advance in health better [31–34]. In this area of research interest,
correlation between the knee functioning is associated with mental and physical strength in
some studies [32], while they are not linked in some other studies [35]. Research on
recovery of TKA patients’ resilience is following the steps of the Fear-Avoidance of Pain
(FAP) model. Avoidance and confrontation are the two outcomes suggested of a TKA
patient experiencing pain. Anxiety and negative thinking appeared to impact the patients’
mental and physical activities in a negative fashion [36]. The avoidance sequential steps are
correlated [37, 38]. The pathway to recovery is rather complicated to define; Patients
without pain fear are observed to be likely to confront it and eventually recover [36].
Researchers focused on the missing elements of the FAP model, and the following are some
of the recent attempts to build furthermore on the model:
Pre-, during, and posthospitalization of TKA patients’ assessment in [28] indicated a
prospective efficacy-engagement path to recovery; this is the Approach-Avoidance
Model of Pain suggested by the authors for a comprehensive understanding of the painful
experiences of the patients.
The factors pointed out to be missing in FAP model in [39] are understanding how
patients function despite pain and how they attempt to recover.
Possible adaptive coping strategies that relate to behavior, cognition, and effectiveness
can fill in the gaps observed in the FAP model [28].
6.1 Self-Efficacy
Research on self-efficacy is observed to be a strong factor in maximizing TKA postsurgical
patient satisfaction and the associated patient reported positive outcomes. Self-efficacy is
described as an individual’s belief in their capacity to act in the ways necessary to reach
specific goals with planning and execution of specific actions. A person with self-efficacy
would circumvent the challenges by viewing them as obstacles to overcome rather than
avoiding these threads [40]. Likelihood of patients’ chronic pain confrontation is high if
they have high functional self-efficacy, and they are also likely to begin a pathway towards
recovery [41]. The level of self-efficacy is determined to tune the level of coping with
painful experiences [46]. Additionally, patients that had negative expectations regarding to
their pain did not recover as well as expected [42]. Less pain experiences and disability are
reported by the patients who had a strong sense of self-efficacy during 1-year follow-ups
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[43]. Patients’ preoperative self-efficacy are determined to be correlated with their
postoperative TKA emotional functioning [44]. This factor can be particularly essential
during the physical therapy recovery of TKA patients. Pain reduction efforts of arthritis
patients after an attempt of increasing their self-efficacy evidenced to pay off according to
[45]. We recommend researchers to investigate how facial plastic surgery patients’ selfefficacy level impact their decisions to undertake facial plastic surgeries.
6.2 Positiveness
Positive affect consists of pleasant state of emotion or moods encouraging approachoriented behaviors or promote a sense of relaxation or contentment. The protective effect of
positiveness on experimental patients and several chronic pain cohorts is studied during
their emotional responses to pain and perception of pain [47]. Positive emotions present in
osteoarthritis patients experiencing significant pain (or patients that are experiencing
diseases that can cause significant pain) is observed to have reduced pain severity [48–50].
The impact of positiveness during daily life activities of patients can result in stress
reduction and therefore aid them during their pain management and reduction. Boosting the
factors that increase positiveness in TKA patients’ life can be the encouraging recovery
method that maximizes PROM values [51]. Positive affective processes are determined to
underlie positive health behavior change [53].
One other factor that positiveness indirectly impacts is identified to be the physical
activities of the TKA patients. Positive mental state of TKA patients in the mornings is
determined to be impactful on their increased daily activities, while the opposite is observed
for the patients with negative mental state in the mornings [52]. The increased level of
positiveness can also boost other behavioral factors that can influence recovery; therefore,
one can conclude that positiveness can be one of the key variables in optimizing
postoperative TKA patient satisfaction We recommend researchers to investigate how facial
plastic surgery patients’ positivity level impact their decisions to undertake facial plastic
surgeries.
6.3 Vigor
“A combination of positive energy balance and pleasantness or contentment” is defined as
the vigor in [55] that “represents a moderate level of arousal.” Vigor has similar impact on
TKA patients that positiveness has; it serves as a resilience factor for coping with
challenges and stress [56]. Vigor, as a variable of energy level, can boost identifying and
pursuing goals of TKA patients through approach-oriented encouragement for recovery and
rehabilitation [55, 57]. The physical and mental states of patients are impacted by vigor that
also correlates with moderate level exercise [54]. High level vigor is observed to enhance
life satisfaction, cope with pain, boost recovery, and improve walking distances [59]. We
recommend researchers to investigate how facial plastic surgery patients’ vigor level
impacts their decisions to undertake facial plastic surgeries.
6.4 Vitality
Vitality is defined as “a psychological sense of aliveness, enthusiasm, or energy” which is
“a positive feeling of having energy available” that “consists of restorative properties” as “a
force that can be harnessed by individuals to maximize personal resources for action” [54].
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Vitality, like vigor and positiveness, impacts physical and mental states of patients as
one of the key variables of energy generation. Physiological conditions during early stages
of osteoarthritis, such as muscle strength and body functioning mechanism limitations, are
observed to relate to low level of vitality [58]. Vitality and vigor are observed to have the
following common impact on TKA patients:
Positiveness levels of TKA patients.
Serves as a resilience factor for coping with challenges and stress [56].
Can boost identifying and pursuing goals of TKA patients through approach-oriented
encouragement for recovery and rehabilitation [55, 57].
Physical and mental state improvements of patients with moderate level exercising [54].
High-level vitality enhances life satisfaction, ability to cope with pain and recovery, and
improved walking distances [59]. We recommend researchers to investigate how facial
plastic surgery patients’ vitality level impact their decisions to undertake facial plastic
surgeries.
7 Engineering Facial Plastic Surgeries and Future Work
In this work, we covered several psychological factors that play a role in facial plastic
surgery patients’ decision to undertake facial plastic surgeries. There are technologies that
can be incorporated into patients’ lives that may limit the increasing number of facial plastic
surgeries and increase their well-being. One possible research area that can be investigated
is the impact of various technologies’ impact on potential facial plastic surgery patients to
decline their decisions to undertake surgeries. Such technologies can include virtual reality
tools and cellular applications. Such technologies used in the right way can help with the
advancement of psychological states of persons to even change their minds about
undertaking facial plastic surgeries. Other technologies that relate to plastic surgery, total
hip arthroplasty, and total knee arthroplasty are reported in [20, 63, 82–114].
As covered in this work, in 2019, 72% percent of American Academy of Facial Plastic
and Reconstructive Surgery (AAFPRS) members reported seeing patients seeking cosmetic
procedures to look better for their selfies, which was up by 15% from 2018. Similarly, more
patients in 2019 went under cosmetic procedures due to dissatisfaction with their profile
images with an observed 11% increase from 2018. Additional factors that motivated
people’s interest in facial plastic surgery included celebrities’ influence on them as well as
the minimal invasiveness of the new technologies [18]. Noting these factors, expansion in
the number of social media channels with ever-increasing interest of young population in
social media appear to have impact on the facial plastic surgery decisions. This has also
been seen with an increase in the persons who decide to undertake facial plastic surgery
between ages 20 and 30 when compared with the population over 30years old. One
research area would be to investigate the facial plastic surgery interest difference between
populations that are highly exposed to social media and those that are not exposed to social
media.
One other way to engineer psychological factors of facial plastic surgery candidates
would be to increase their self-efficacy, positive attitude and exposure to positive attitude,
vitality, and vigor before and after facial plastic surgeries. Finding creative ways to increase
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these factors on patients and calculating the associated measurable outcomes can be a way
to improve reduction of facial plastic surgeries.
We asked the following question regarding the power of brain/mind and its impact on
plastic surgery decisions:
Is the physical appearance causing an unnecessary mental barrier in one’s mind to be
social, make friends, and be popular?
Even though we didn’t seek an answer to this question in this work, we hypothesized
that the physical appearance causes an unnecessary mental barrier in one’s mind to be
social, make friends and be popular. The response to the abovementioned question relates to
the power of mind and mental construction of a person to be popular or make friends. One
can test the effectiveness of virtual reality or gaming strategies and measure these
technologies’ impact on youth to improve their mental strength.
As we pointed out previously, media such as magazines, television, and music, along
with social media such as Tweeter, Facebook, etc., have a strong coverage of the world’s
population, with psychological impact on those persons following these channels. To the
best of our knowledge, there has not been an extensive study to determine the psychological
impact of media and social media on facial plastic surgery (or general plastic surgery)
decisions. We invite researchers to investigate furthermore in this area of interest.
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