There has been an increase in demand for non-surgical facial aesthetic treatments over the last decade, with predictions that in the United Kingdom this industry could be worth up to three billion pounds (LaingBuisson, 2018). According to the Keogh Review (Department of Health, 2013), non-surgical facial aesthetics treatments make up nine out of ten cosmetic treatments in the United Kingdom.
The growing popularity of facial aesthetics procedures highlights the need to investigate and understand the factors motivating patients to seek these treatments. In addition to exploring the reasons why patients seek facial aesthetics treatments, it is also important to have awareness of the patient characteristics that will predispose them to non-ideal post-procedural outcomes. Available evidence indicates that some patients choose to have non-surgical facial aesthetic procedures because they believe it would yield psychosocial benefits and resolve problems in other areas of their lives (James et al, 2019). These patients are, paradoxically, at increased risk of suffering post-procedural dissatisfaction and psychological harm (Herruer et al, 2015). This emphasises the importance of assessment as part of a patient-centred, holistic care plan to identify any high-risk patient factors and prevent missed safeguarding opportunities.
Despite recent changes in legislation to allow the government to introduce a licensing scheme for practitioners working in England (Health and Care Act 2022), there is no nationwide recognised educational, training and practising pathway (JCCP, 2022). Consequently, knowledge, ethics and practice standards will vary between clinics, including the quality of the patient assessment in relation to their movitation for seeking treatment in the first place.
» Available evidence indicates that some patients choose to have non-surgical facial aesthetic procedures because they believe it would yield psychosocial benefits and resolve problems in other areas of their lives. These patients are, paradoxically, at increased risk of suffering post-procedural dissatisfaction and psychological harm «
This systematic review therefore aims to address these issues by investigating the patient factors associated with seeking non-surgical facial aesthetics treatments. It therefore improves practitioners' assessment process by increasing awareness of patient characteristics and what they may imply in relation to reasons for receiving treatment. Gaps in the literature, wherever relevant, are also identified.
Methods
This review is based on carefully chosen evidence available following systematic appraisal of the literature (Centre for Evidence Based Medicine, 2009) and is conducted according to the PRISMA statement guidelines (PRISMA, 2021).
The PubMed and Northumbria University Library databases were searched using the following terms: adults, facial aesthetics, non-surgical facial aesthetics, botulinum toxin, Botox®, Bocouture®, Azzalure®, preventative Botox®, filler, dermal filler, nonpermanent dermal filler, skin rejuvenation, facial rejuvenation, motivation, motivational factors, life events and psychology. Primary research studies from peer-reviewed journals were considered, including qualitative, quantitative and mixed methods research. Publication dates of selected articles were restricted to the last ten years. Studies in the English language were included, regardless of the country of origin. See Tables 1 and 2 for more information.
Table 1. Databases searched and search terms
| Databases searched | Searched terms |
|---|---|
|
Adults, facial aesthetics, non-surgical facial aesthetics, botulinum toxin, Botox®, Bocouture®, Azzalure®, preventative Botox®, filler, dermal filler, non-permanent dermal filler, skin rejuvenation, facial rejuvenation, motivation*, motivational factors, life events, psychology. |
Table 2. Criteria for choosing articles
| Inclusion criteria | Exclusion criteria |
|---|---|
|
|
Studies on patients both considering non-surgical facial aesthetic treatments and proceeding with treatments were included. Clear aims and methodology as well as the mention of ethical approval and consent were part of the main criteria as well. For clarity, these processes are outlined in Figure 1.
» This growing popularity of facial aesthetics procedures highlights the need to investigate and understand the factors motivating patients to seek these treatments «
Studies selected for a deeper look
After the selection process, six studies were identified. Table 3 summarises the included studies and factors predicting interest in non-surgical facial aesthetic procedures. Drawing on these studies, factors influencing the uptake of non-surgical facial aesthetic treatments in adults are discussed.
Table 3. Summary of studies
| Author(s) | Year | Number of Patients | Motivating factors |
|---|---|---|---|
| Dadkhahfar et al | 2021 | 111 | Sociodemographic, knowing family members who had procedures, major life event |
| D'Agostino et al | 2018 | 48 | Narcissistic/depressive personality disorder traits |
| Jin et al | 2022 | 8089 | Sociodemographic, history of depressive symptoms and smoking, appearance dissatisfaction |
| Maisel et al | 2018 | 511 | Sociodemographic, history of prior treatment, desire to look more attractive for themselves |
| Milothridis et al | 2017 | 200 | Medical professional and burnout syndrome |
| Ramirez et al | 2021 | 624 | Sociodemographic, history of prior treatment, facial rejuvenation to improve confidence for themselves. |
Sociodemographic factors underpinning the uptake of non-surgical facial aesthetic treatments
The following are some sociodemographic factors underpinning the uptake of non-surgical facial aesthetic treatments:
Age
The included studies sought to examine interest in treatments in patients over 18 years old. It was found that interest was shown primarily in the over-30s age group, with the exception of Jin et al (2022) whose cohort were aged between 17 and 25 years old. Dadkhahfar et al (2021) reported that the mean age of participants was 39.6 years, and this was similar to findings from Ramirez et al (2021), who revealed that 53.1% of interested patients were 40 years old and above. Maisel et al (2018) found that 53.1% of patients presenting for treatment were at least 45 years old, whereas Milothridis et al (2017) and D'Agostino et al (2018) documented a slightly younger average age of patients, at 34 years and 30 years respectively. Table 4 summarises age as a factor in the uptake of non-surgical facial aesthetics.
Table 4. Age as a factor in the uptake of non-surgical facial aesthetics
| Study | Findings |
|---|---|
| Dadkhahfar et al (2021) | Mean age of interested participants was 39.6 years |
| Ramirez et al (2021) | 53.1% of interested patients were 40 years old and above |
| Maisel et al (2018) | 53.1% of patients presenting for treatment were at least 45 years old |
| Milothridis et al (2017) | Mean age of interested patient was 34 years |
| D'Agostino et al (2018) | Mean age of interested patient was 30 years. |
Gender
All studies, except for D'Agostino et al (2018), who did not record the gender of participants, found that women were more interested in non-surgical facial aesthetics treatments than men. Dadkhahfar et al (2018) reported that out of 111 participants attending a dermatology outpatient centre for non-surgical facial aesthetics, 94 (84.7%) were female. In addition, more women requested dermal filler treatments than men (34.9% versus 11.8%, p<0.44). In a study by Jin et al (2022), 63.3% of female students went on to have non-surgical facial aesthetics treatment compared to 36.7% of male students. Binary logistic regression analysis of the results in this study showed that being female was independently associated with interest in these treatments (p<0.001). 86% of 511 participants in the study by Maisel et al (2018) presented for non-surgical facial aesthetics treatments were women.
Milothridis et al (2017) found that overall, females were more interested than males in non-surgical treatments than males (p<0.001). Similarly, out of 624 patients seeking non-surgical facial aesthetics treatments, Ramirez et al (2021) reported that 86.9% were women. Table 5 is an outline of the role of gender in taking up non-facial aesthetic treatments.
Table 5. Gender as a factor in the uptake of non-surgical facial aesthetics
| Study | Findings |
|---|---|
| Dadkhahfar et al (2021) |
|
| Ramirez et al (2021) | Out of 624 patients seeking non-surgical facial aesthetics treatments, 86.9% were women |
| Maisel et al (2018) | 86% of 511 participants presenting for non-surgical facial aesthetics treatments were women |
| Milothridis et al (2017) | Women were more interested than men in non-surgical treatments (p<0.001) |
| Jin et al (2022) | 63.3% of women went on to have non-surgical facial aesthetics treatment compared to 36.7% of men. Binary logistic regression analysis of the results in this study showed that being female was independently associated with interest in these treatments (p<0.001). |
Education level
Of all studies, education level was a prominent factor among those seeking treatments. Dadkhahfar et al (2021) found that 61.3% of interested participants were educated to degree level. This finding is similar to Maisel et al (2018), who found 91.8% of patients were college-educated. Milothridis et al (2017) were investigating doctors and non-medical professionals, revealing that all participants were educated to degree level. In addition, interestingly, this study reports that doctors were more likely than non-medics to seek facial aesthetics treatments (p<0.035). See Table 6 for an outline of education and treatment uptake.
Table 6. Education as a factor in the uptake of non-surgical facial aesthetics
| Study | Findings |
|---|---|
| Dadkhahfar et al (2021) | 61.3% of interested participants were educated to degree level |
| Maisel et al (2018) | 91.8% of patients were college educated |
| Milothridis et al (2017) |
|
| D'Agostino et al (2018) | 75% of participants were educated to secondary school level. |
» The main psychosocial reasons for seeking treatments were intrinsic, with patients seeking facial rejuvenation to improve their self-confidence and maintain their well-being … «
Treatment history and lifestyle
Patients with a previous history of facial aesthetics treatments were more likely to proceed with further treatments. Dadkhahfar et al (2021) found 51.8% of interested participants had at least one treatment before; Interest in non-surgical facial aesthetics may be indicative of certain personality types and psychosocial characteristics, such as history of depression, narcissistic personality disorder traits and burnout syndrome. There is a substantial amount of research proving that seeking cosmetic surgery is associated with depression (Qian et al, 2021) and borderline personality disorder (Morioka and Ohkubo, 2014). Little research has been carried out for non-surgical procedures, however Özkur et al (2019) found that candidates presenting for non-surgical treatments had higher levels of psychiatric problems than the control subjects.
Maisel et al (2018) reported that 52.8% had at least two treatments previously, whereas Ramirez et al (2021) found that patients who had a history of treatment were more likely to proceed than those with no prior treatment experience (p<0.009). In addition, this study found that expectations of immediate results increased likelihood of proceeding with treatment (p<0.043). Lifestyle-wise, Dadkhahfar et al (2021) and Ramirez et al (2021) reported regular sunscreen use as a factor (58.5%, p<0.01; and 45% respectively). Ramirez et al (2021) also found that the same number of interested participants did not smoke, which is contrary to Jin et al (2022), who found a positive correlation between smoking and interest in facial aesthetics treatments (p<0.05). Table 7 delineates a summary of treatment history and treatment uptake.
Table 7. Treatment history as a factor in the uptake of non-surgical facial aesthetics
| Study | Findings |
|---|---|
| Dadkhahfar et al (2021) | 51.8% of interested participants had a history of at least one prior treatment |
| Ramirez et al (2021) |
|
| Maisel et al (2018) | 52.8% had a history of at least two prior treatments. |
Psychological factors and life events
The study by D'Agostino et al (2018) measured the different personality traits that might be present in patients seeking surgical (G1) and non-surgical (G2) aesthetic treatments compared to those not seeking treatment (G3). In general, G1 had higher anxiety scores than G2 (p<0.05). Jin et al (2022) found that students with depressive symptoms were more likely to seek non-surgical treatments (p=0.041); however, interested participants were more likely to have good relationships with their mother (p<0.0001) and father (p=0.04). In contrast to this, D'Agostino et al (2018) found family conflicts in G1 and G2 (between G1 and G2 p<0.05). Marital difficulties were found in both G1 and G2.
Table 8. Psychological elements and life events as a factor in the uptake of non-surgical facial aesthetics
| Study | Findings |
|---|---|
| Dadkhahfar et al (2021) |
|
| Milothridis et al (2017) |
|
| D'Agostino et al (2018) |
|
| Jin et al (2022) |
|
» … however, a positive correlation exists between history of depression, professional burnout, and narcissistic personality disorder traits and interest in non-surgical facial aesthetics treatments «
The only other study to report on life events is Dadkhahfar et al (2021), who found that 50% of participants were seeking aesthetic treatment following the death of a family member and 26.9% were preparing for marriage. D'Agostino et al (2018) also investigated personality disorders or personality disorder traits among those interested in non-surgical treatments. The structured clinical interview for DSM-IV (First et al, 1997) scales showed that for G2, there was one participant with Narcissistic Personality Disorder (NPD), five with NPD traits and ten with no disorders or traits. Dhadkhahfar et al (2021) reported that 14% of interested participants attended a psychiatrist and 16% were taking psychiatric drugs, whereas Jin et al (2022) did not find any significant difference in psychiatric history between those seeking treatment and those who were not. Milothridis et al (2017) found a positive correlation between interest in aesthetic procedures and both dimensions of burnt-out syndrome (emotional exhaustion and depersonalisation).
Motivation: intrinsic and extrinsic
Several studies revealed that patients' main driving factor for seeking non-surgical treatments was intrinsic motivation. Dadkhahfar et al (2021) found that out of 111 participants, 39.2% were seeking facial aesthetics for internal reasons such as rejuvenation to improve self-confidence. This was similar to findings by Maisel et al (2018), who reported the main motivations for appearance and emotional well-being as looking younger (391 of 469, (83.4%)), having clear skin (382 of 469 (81.4%)) and looking better for themselves (417 of 471 (88.5%)). Ramirez et al (2021) found a link between proceeding with treatment and a desire for facial rejuvenation (p=0.014). Table 9 delineates the relationship between motivation and treatment uptake.
Table 9. Motivation as a factor in the uptake of non-surgical facial aesthetics
| Study | Findings |
|---|---|
| Dadkhahfar et al (2021) |
|
| Ramirez et al (2021) |
|
| Maisel et al (2018) |
|
| Jin et al (2022) |
|
Discussion
This review showed link between individuals over the age of 30 and peaked interest in facial aesthetics treatments. In these studies, this age group was more focused on facial rejuvenation and was more likely to seek treatments to reverse the effects of ageing and improve psychological well-being (Honigman and Castle, 2006).
In all studies, facial aesthetics treatments were sought by women more than men. A review by Alotaibi (2021) found that 90% of participants across all cultures studied, that were interested in cosmetic procedures, were women. A survey by Glass et al (2015) confirmed that women were more willing to take part in research, particularly if they had information or experience in the subject matter. This is consistent with the increased interest in facial aesthetics and previous treatment history finding.
Employed individuals and those educated to degree level seemed to have more interest in facial aesthetic procedures. Sobanko et al (2015) speculated that it could be due to better informed patients wishing to avoid the more extreme side effects of invasive procedures, and the minimal downtime associated with non-surgical treatments. Women in this category, therefore, are not necessarily patients subject to psychological harm.
The review also showed that those with a history of receiving facial aesthetics treatments were more likely to seek treatment again. According to McKeown (2021), patients seeking treatment to improve self-confidence would have a more satisfactory outcome and therefore return for repeated treatments. Contrary to this, repeated patterns of seeking treatment can be a sign of Body Dysmorphic Disorder (BDD) (Gorbis, 2019). This was not measured in any of the included studies and is out with the scope of this review, however practitioners must be aware of the signs of BDD as treating these patients could increase their anxiety and appearance dissatisfaction (Bjornsson, Didie and Phillips, 2010).
Contrary to the findings in some similar studies in the literature, this review found a link between intrinsic motivational factors and non-surgical facial aesthetics. A literature review by the Nuffield Council on Bioethics found that the main motivational factors to pursue both surgical and non-surgical treatments were societal pressure, celebrity influence, social media influence and placement of high value on other's opinions. Research by Sobanko et al (2015) supports the findings of intrinsic motivations such as improving self-appearance and quality of life for seeking non-surgical procedures. As suggested previously, this may be due to increased patient awareness on the benefits and limitations of non-surgical procedures.
Beyond factors: implications of this analysis
According to an article by Haswell (2019), aesthetic patients should only be treated if benefit would be provided in terms of a patient's appearance, mental well-being, self-esteem, or confidence. The findings from this review help shape the meaning and implications that certain motivations have for both practitioners and patients. Although practitioners have a duty to uphold the principal of autonomy (Huxtable, 2014), an ethical practitioner will assess the patient and identify when treatment may not be in the patient's best interests. This is a safeguarding requirement by the JCCP as part of the patient assessment (JCCP, 2015). The patient consultation should include a detailed assessment of motivations for treatment, including why they are seeking treatment and what they would like to change, with expected treatment goals. It is the practitioner's duty to ensure they do not treat patients with unrealistic expectations as it may result in perceived unsatisfactory outcomes for the patient leading to decreased psychological well-being and poorer quality of life, as well as litigation against the practitioner (Brackenbury, 2014). According to Jindal and Gupta (2022), patients seeking aesthetic treatments with psychiatric disorders perceive their problem to be cosmetic rather than psychological. Depression and anxiety can occur post-procedure and may be exacerbated in patients with existing mood disorders (Jones et al, 2022). The evidence in this review has shown that some patients who seek facial aesthetics treatments have personality disorder traits, a history of depression or side effects from burnout syndrome. Ideally, practitioners should screen prospective patients to determine risk of poor post-procedure outcome. This should be completed within their scope of practice, as most practitioners will not be trained to diagnose psychiatric conditions (see Nursing and Midwifery Council for further reading). If there are any concerns about the patient's mental health, then practitioners should refer for psychiatric evaluation as per local guidelines (see National Institute for Health and Care Excellence for further reading). Patient safety and well-being should be a priority for practitioners, both out of professional integrity and improving public confidence in the non-surgical aesthetics sector.
Several limitations need to be noticed in this review. The lack of research on this emerging subject limits the generalisability of the results. In addition, most studies are observational and cannot establish a true causal relationship (Setia, 2016). The finding that treatment is mostly sought by women could be due to overrepresentation in the samples. However, this is a relatively new area of research, and this review gives a good starting point for further exploration of this complex subject.
Conclusion
This review found that most patients seeking non-surgical facial aesthetics treatments were educated women over the age of 30 with prior experience of receiving these treatments. The main psychosocial reasons for seeking treatments were intrinsic, with patients seeking facial rejuvenation to improve their self-confidence and maintain their well-being, however a positive correlation existed between history of depression, professional burnout, narcissistic personality disorder traits and interest in non-surgical facial aesthetics treatments. While it is necessary to remember that not all patients seeking treatments are at psychological risk, understanding the factors associated with non-surgical treatment uptake could still help identify patients who would benefit most from the procedure and help improve the quality of patient assessment. Further qualitative research would be useful as this could potentially give greater insight into patients' views, as well as allowing the researcher flexibility to tailor future rounds of questions.
Key points
- Non-surgical facial aesthetics are increasing in popularity, yet the reasons why patients seek them are not well researched
- This review found that patients interested in treatments were often middle aged, well-educated women wishing to improve their self-confidence
- The review also found a positive correlation between interest in treatments and depression, narcissistic personality disorder traits and burnout syndrome
- It is important to have knowledge of patient motivations to identify who will benefit from treatment and who may be at psychological risk when receiving treatments
- The lack of research in this area, however, implies that the generalisation of the review findings may be limited
- Further qualitative research could be valuable in this area for greater patient insight.
CPD reflective questions
- Why is knowing the motivational factors of patients such an important part of the assessment?
- What are the main motivational characteristics discussed in this review?
- How will awareness of these factors help future clinical practice?