## Abstract

Background: Understanding patient interest in cosmetic surgery is an important tool in delineating the current market for aesthetic surgeons. Similarly, defining those factors that most influence surgeon selection is vital for optimizing marketing strategies.

Objective: The authors evaluate a general population sample's interest in cosmetic surgery and investigate which factors patients value when selecting their surgeon.

Methods: An anonymous questionnaire was distributed to 96 individuals in waiting rooms in nonsurgical clinics. Respondents were questioned on their ability to differentiate between a “plastic” surgeon and a “cosmetic” surgeon, their interest in having plastic surgery, and factors affecting surgeon and practice selection. Univariate and multivariate analyses were conducted to define any significant correlative relationships.

Results: Respondents consisted of 15 men and 81 women. Median age was 34.5 (range, 18–67) years. Overall, 20% were currently considering plastic surgery and 78% stated they would consider it in the future. The most common area of interest was a procedure for the face. The most important factors in selecting a surgeon were surgeon reputation and board certification. The least important were quality of advertising and surgeon age. The most cited factor preventing individuals from pursuing plastic surgery was fear of a poor result. Most (60%) patients would choose a private surgicenter-based practice.

Conclusions: The level of importance for each studied attribute can help plastic surgeons understand the market for cosmetic surgery as well as what patients look for when selecting their surgeon. This study helps to define those attributes in a sample population.

Over 9 million cosmetic surgical and nonsurgical procedures were performed in the United States in 2011.1 This represented a small increase of 0.1% from 2010. Although nonsurgical procedures accounted for 82% of the total number of procedures, surgical procedures accounted for 63% of the nearly $11 billion expenditure.1 This continued growth in demand for cosmetic surgery is particularly impressive as it is occurring in the midst of one of the more significant economic recessions in the nation's history.2 Coinciding with the increase in demand, there has been a steady increase in the number of providers who can offer both surgical and nonsurgical care in cosmetic procedures. There are currently an estimated 7943 board-certified plastic surgeons in the United States.3 However, this number is a profound underestimate of practicing cosmetic surgeons. When we consider that physicians from a myriad of other training backgrounds (eg, otolaryngologists, dermatologists, etc) have established cosmetic practices, the true number of cosmetic practitioners is clearly significantly higher. Indeed, given that a practitioner needs only a medical license to legally practice cosmetic surgery, it is nearly impossible to estimate the number of providers available to patients. The field of cosmetic surgery continues to be a predominantly patient-driven market. This is complicated by the public's general lack of understanding of what it means to be a “plastic” or “cosmetic” surgeon.4–6 Patients seeking plastic surgery now have more options in terms of potential providers and procedures than ever before. In contrast to most medical fields, the elective nature of cosmetic procedures suggests that the surgeon must seek out patients as much as patients seek out their surgeons.7 To that end, physicians engaged in the practice of cosmetic surgery commonly employ public relations experts and engage in widespread advertising in marketing-related endeavors.8,9 Although there has been some investigation into factors influencing procedure and surgeon selection,10,11 there is a relative paucity of published research on the topic. (In this context, the competition continues to grow as more physicians—plastic and non–plastic surgeons alike—introduce themselves as cosmetic providers.) Given the continued growth of this field, even in the face of economic hardship, and the patient-driven nature of the field, it is increasingly important to understand the patient's mind-set. Defining the factors that influence a patient's interest in plastic surgery and delineating what drives a patient to select a particular surgeon are invaluable for the cosmetic practitioner.12 This study examines subjects who were not affiliated with a surgeon's practice at the time of participation. It therefore provides a glimpse into the thought process of the general population. From these subjects, this study intends to investigate those factors that influence a patient's interest or lack of interest in cosmetic surgery. In addition, this study evaluates those criteria most important to patients when selecting their surgeon. ## Methods ### Participants Subjects were recruited over a 3-month period at 4 primary care clinics in the greater Los Angeles area. The study sites included 2 internal medicine clinics, 1 family practice clinic, and 1 pediatric clinic. Participants were given the survey as part of their intake paperwork for the clinic. Participation was voluntary and anonymous. Subjects younger than 18 years of age were excluded. Completed surveys were placed in a secured dropbox. ### Survey The survey study was conducted under approval from the University of California Los Angeles Institutional Review Board (IRB 124212B). Respondents were asked to provide standard demographic information on age, sex, household income, and marital status. In addition, they were questioned about their own history of plastic surgery performed or considered. Respondents were asked to identify training paths and specialties that could produce a cosmetic surgeon; options included surgeon, dentist, obstetrician/gynecologist, anesthesiologist, family practitioner, internist, and dermatologist. Subjects were then asked to identify the area of the body they would be most interested in having treatment for with plastic surgery, as well as the principal reason they would not have plastic surgery. Questions directed at surgeon selection included importance of advertisement, reputation, type of referral, board certification, surgeon age, training background, and quality of practice. For these questions, respondents were asked to rate the importance of each factor on a scale of 0 to 10, where 0 was least important and 10 was most important. Potential respondents were questioned on where they would prefer to undergo plastic surgery: at a private surgicenter, a community hospital, or a university medical center. Finally, respondents were asked to express their preference for a larger, more expensive procedure with longer lasting results or a shorter, less-expensive procedure with more temporary results. The full questionnaire is available in Appendix 1 at www.aestheticsurgeryjournal.com. ### Data Analysis Only responses with data available for all of the demographic variables were used; respondents who failed to choose at least 1 response for each question were excluded. Descriptive statistics were obtained for the demographic variables to describe the sample. Income was categorized in US dollars as$0 to 45 000 (low income), $45 000 to$100 000 (middle income), and >$100 000 (high income). An ordinal logistic regression model was then manually fit for the total for plastic surgery with age, sex, marital status, and income. Cross-tabulated frequencies were calculated and chi-square associations were computed among the association variables. A linear analysis of income was also employed to assess correlations with associated variables. ## Results ### Demographics Ninety-six subjects responded to the survey. Average respondent age was 34.5 years (range, 18–67 years). Eighty-one (84%) were women and 15 (16%) were men. Average annual household income of participants was$91 298 (range, $0 to$500 000). If we eliminated the participants who reported an annual income of $0, the average annual household income rose to$106 886 (±SE $9607). Forty-two participants were single and 54 (56.2%) were married. Sixteen respondents (16.7%) had previously undergone cosmetic surgery (Table 1). Table 1 Respondent demographics.  Age, y, mean (range) 34.5 (18–67) Income,a$, mean (range) 91 298 (0–500 000) Sex Male 15 (15.6) Female 81 (84.4) Marital status Yes 54 (56.3) No 42 (43.8) Previous plastic surgery Yes 16 (16.7) No 80 (83.3)
 Age, y, mean (range) 34.5 (18–67) Income,a $, mean (range) 91 298 (0–500 000) Sex Male 15 (15.6) Female 81 (84.4) Marital status Yes 54 (56.3) No 42 (43.8) Previous plastic surgery Yes 16 (16.7) No 80 (83.3) Values are presented as No. (%) unless otherwise indicated. a Adjusted mean ± SD, without participants who reported an annual income of$0: $106 886 ±$9067.

### Defining a “Cosmetic” Surgeon

Among participants, 32 (33.3%) did not draw a distinction between a plastic surgeon and a cosmetic surgeon (Figure 1A). All respondents identified “surgeon” as a training path that could yield a cosmetic surgeon; 33 (34.4%) said that surgeon was the only training path that could yield a cosmetic surgeon. The remainder of subjects identified dermatologist (34%), dentist (22%), obstetrician/gynecologist (22%), anesthesiologist (12%), family practitioner (12%), and internist (10%) as training paths capable of yielding a cosmetic surgeon. Only 8 respondents (8.3%) selected all available training paths. There was no statistically significant correlation between these responses and age, sex, income, or marital status (Figure 1B).

Figure 1

(A) Responses to the question, “Do you draw a distinction between a plastic surgeon and a cosmetic surgeon?” (B) Responses to the question, “Which of the following training paths can produce a cosmetic surgeon?” Anes, anesthesiologist; Derm, dermatologist; OB-Gyn, obstetrician/gynecologist.

Figure 1

(A) Responses to the question, “Do you draw a distinction between a plastic surgeon and a cosmetic surgeon?” (B) Responses to the question, “Which of the following training paths can produce a cosmetic surgeon?” Anes, anesthesiologist; Derm, dermatologist; OB-Gyn, obstetrician/gynecologist.

### Interest in Plastic Surgery

Nineteen subjects (19.8%) were considering cosmetic surgery at the time they completed the survey. Seventy-five subjects (78.1%) said they might consider cosmetic surgery in the future. Overall, surgery of the general face was identified most frequently (44.8%) as the surgery in which most individuals would be interested. Younger participants tended to be most interested in cosmetic breast surgery (mean age, 30.6 years), while older participants tended to be most interested in cosmetic surgery of the face (mean age, 35.4 years; P = .02). Subjects were least interested in cosmetic surgery for the extremity or neck (n = 0 and n = 4, respectively; Figure 2A).

Figure 2

(A) Responses to the question, “On which part of the body would you be MOST interested in having plastic surgery?” (B) Responses to the question, “Which of the following is the principal reason you would NOT have plastic surgery?”

Figure 2

(A) Responses to the question, “On which part of the body would you be MOST interested in having plastic surgery?” (B) Responses to the question, “Which of the following is the principal reason you would NOT have plastic surgery?”

Fear of a poor result (51%) was the most common reason given for not undergoing plastic surgery. Other reasons were cost (40.6%), fear of the recovery process (25%), fear of anesthesia/surgery (14.6%), and no interest (20.8%). No respondents identified fear of what others might think as a reason not to pursue plastic surgery (Figure 2B). When compared with unmarried individuals, subjects who were married were more likely to choose a more expensive surgery with longer lasting results over a less invasive procedure offering more temporary benefits. There was no statistically significant correlation between preference for a permanent or temporary procedure and age, sex, or income.

### Factors Influencing Selection

Average score for factors viewed by respondents as most important when considering a plastic surgeon are illustrated in Figure 3. Surgeon reputation (9.21 on a scale of 0-10) and board certification (9.20) were the most important factors indicated by subjects. Age (5.49) and advertisement (2.63) were identified as least important. Those with no history of prior surgery tended to value referral from a friend more highly than those with a history of prior surgery (Figure 3A). Most respondents (60.4%) would choose a private practice surgicenter for the site of their surgery followed by a university medical center (36.5%) and a community hospital (4.1%). The rate of preference for surgery location (surgicenter vs university medical center) was significantly different for those individuals who had undergone prior plastic surgery versus those who had not (83.3% vs 56%, respectively; P = .03). There was no statistically significant correlation between preference for surgery location and age, sex, or income (Figure 3B).

Figure 3

Responses to the question, “How important would each of the following be when considering your plastic surgeon?” Respondents rated each category on a 0 to 10 scale, with 10 representing the most important factor. (B)Responses to the question, “Where you would prefer to have plastic surgery done?”

Figure 3

Responses to the question, “How important would each of the following be when considering your plastic surgeon?” Respondents rated each category on a 0 to 10 scale, with 10 representing the most important factor. (B)Responses to the question, “Where you would prefer to have plastic surgery done?”

## Discussion

Demand for cosmetic surgery in the United States continues to rise even with the backdrop of economic recession. Furthermore, an increasing number of providers from plastic surgery backgrounds and non–plastic surgery backgrounds alike are offering services to cosmetic patients. Understanding the general public's interests as well as the factors they consider when selecting both procedure and surgeon are vital to the success of any cosmetic practitioner. This study attempted to investigate not only the general public's interest in cosmetic surgery but also the criteria considered by members of the public when moving forward with procedure and provider selection.

Our study findings are consistent with the continued demand for aesthetic surgery. Nearly 90% of respondents reported that they would consider plastic surgery in the future. Furthermore, our survey results suggest that cosmetic surgery is becoming increasingly socially acceptable, since not a single respondent cited concern over what others might think of them as a reason not to proceed with surgery. This seems to indicate that the negative stigma that may have been previously present for plastic surgery has been reduced.

An interesting finding in our survey relates to the public perception of the “cosmetic surgeon.” Hamilton et al6 previously investigated this issue and found that the general public considered a cosmetic surgeon different from a plastic surgeon, with the former being thought of as a more temporary, less trained provider. Nearly 70% of respondents in our study also drew a distinction between a plastic surgeon and a cosmetic surgeon. However, only 8 of the 96 respondents correctly pointed to the fact that any physician with a medical degree was legally qualified to perform cosmetic surgery. The remainder of respondents felt that the cosmetic surgeon population was composed of either trained surgeons only or some arbitrary combination of surgical and nonsurgical practitioners (dermatologists, dentists, etc). This is made even more remarkable by the finding that 1 of the primary considerations for respondents in selecting a plastic surgeon was board certification. These findings seem dichotomous. If respondents felt that board certification was important, that would seem to highlight the recognition that not all cosmetic surgeons were board-certified, which should in turn indicate a distinction between a cosmetic surgeon and a plastic surgeon. These results suggest a major deficit in public understanding of what it means to be a board-certified plastic surgeon and what it means to be a cosmetic surgeon, which is consistent with previous findings by Kim et al4 and Dunkin et al,5 who also demonstrated the public's general lack of understanding about which procedures a plastic surgeon is qualified to perform. As suggested by previous studies on public perception, it is imperative that the plastic surgery community educates the general public on this distinction, thereby ensuring that only properly trained practitioners are treating this growing population.

The most important factor for patients in selecting their plastic surgeon was surgeon reputation. The factors creating and constituting “reputation” are, of course, subject to some interpretation. At the very least, “reputation” emphasizes the advantage of established practitioners over new cosmetic surgeons. Board certification in plastic surgery was the second most important factor.

We did not investigate the general public's understanding of what it meant to be a board-certified plastic surgeon in this study. For example, cosmetic surgeons may rightfully state they are board-certified practitioners when, in fact, they are board-certified in a field other than plastic surgery. Just as with the distinction between a plastic surgeon and a cosmetic surgeon, the distinction between American Board of Plastic Surgery certification and other nonaccredited certifications must be clear to the general population. Our data suggest this is not currently the case.

Interestingly, at a time when cosmetic surgeons are dedicating increasingly more resources to marketing, the results of our study indicated that advertising was the least important factor in surgeon selection. These results are somewhat difficult to interpret, however. Certainly, making one's presence known to potential patients is the first step toward being selected as their provider. Nonetheless, it is safe to say that a surgeon should not rely too heavily on a strong advertising campaign in lieu of many of the other factors mentioned in our survey. In fact, our results might indicate that if he or she has developed a good reputation through successful treatment of a group of patients, a board-certified surgeon may be unnecessarily draining resources by investing in expensive advertising campaigns.

Patients cited fear of a poor result, cost, and fear of the recovery process as the principal reasons for refusing cosmetic surgery. We know that thorough preoperative consultation with the patient is often effective in addressing concerns regarding results and the recovery process, but concerns over cost are not surprising in today's economic climate, and they have been shown to affect aesthetic surgery decision making.13 However, the continued increase in nonsurgical procedure rates suggests that patients will continue to undergo aesthetic procedures that are more affordable, even if the expected benefit is more short lived. Nonetheless, presenting the prospective patient with payment plan options such as monthly or deferred payments might address these concerns.

Patients who had previously undergone plastic surgery were more likely than those who had not undergone a previous procedure to choose a private practice surgicenter over a university medical center. There are 2 possible explanations for this finding. First, if these patients had already received their treatment from private surgicenters, they likely experienced high-level personal care and attention, which is a certain advantage of these low-volume centers. Such “patient-centric” practices would only reinforce the patient's desire to return to these settings. Second, if patients had previously undergone surgery at a different type of location, the opposite effect may have occurred, and these patients may crave the increased anonymity and attention of private surgicenters.

Another interesting finding of our study evaluates patient interest in a more expensive, longer lasting surgery (eg, facelift) versus a less expensive, more temporary procedure (eg, botulinum toxin injection). In 2011, Kurkjian et al13 found respondents to be less interested in longlasting but expensive treatments when more affordable and temporary options existed. Furthermore, data from the American Society for Aesthetic Plastic Surgery illustrated growing interest in less expensive, nonsurgical modalities, with less percentage growth in surgical procedures in 2010.1 In this study, the responses to this question showed no correlation with age, sex, or household income. However, married respondents were more likely to select a facelift. This could be explained by the fact that married respondents tended to be older and wealthier. Although age and wealth did not show individual links with a preference for surgical modalities, marriage essentially brought both factors to bear on this question. It would seem logical that older patients would more strongly consider procedures to the face and wealthier patients would select the more expensive option.

This study has other limitations. First, the sample size is small and therefore prone to sampling error. Second, this cohort is not a faithful representation of the general public, as it is geographically confined to Southern California, where, as the survey indicates, the average annual household income ($91 298) is well above that of the national median ($60 088 in 2010).14 However, it should also be noted that in 2010, the income group with the largest number of members in the US census data was the $100 000 to$149 999 group (14.9%). It could also be argued that the population most interested in cosmetic surgery belongs to a higher income bracket than what would be represented by the national median income. Nonetheless, the geographic and income limitations of this study could be addressed with a larger sample size, which would capture a more diverse and therefore more representative survey population.

As the demand for cosmetic surgery continues to rise, additional investigation into this unique patient population is warranted. Defining the demographics of this group as well as those factors patients use in selecting their providers will help plastic surgeons optimize the use of their resources.

## Conclusions

Understanding public interest in aesthetic surgery, as well as the factors that govern patient selection of a surgeon and practice, are essential to the success of the practicing aesthetic surgeon. In our sample general population, nearly 90% of respondents would consider plastic surgery in the future. Surgeon reputation and board certification status were the 2 most important factors for surgeon selection, and the majority of patients preferred a surgicenter setting. Subjects cited fear of a poor result, cost, and fear of the recovery process as the principal reasons for refusing plastic surgery. In a patient-driven field such as aesthetic surgery, insight into the mind-set of potential patients is an invaluable tool to maximize success in the surgeon's practice. Continued study is warranted.

## Editor's Note

Please see the Editorial in this month's issue of the Journal for an extended discussion of the differences between definitions of “plastic” surgery and “cosmetic” surgery in our specialty.

## Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

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