There has been a surge in minimally invasive injectable treatments in aesthetic medicine, such as botulinum toxin and hyaluronic acid fillers [1-4]. This trend has been amplified after the COVID-19 pandemic, with reports of a steeply increasing interest in these procedures [5,6]. This has brought renewed focus to the complex motivations driving individuals to seek these procedures. Although existing research acknowledges an increase in demand, it also reveals a gap in our understanding of the psychological and social factors that influence patient choices in this new era [7-9].

The pandemic, with its “Zoom dysphoria” and increased social media engagement, may have potentially intensified concerns about personal appearance and skin quality, leading to a heightened interest in cosmetic procedures [8,9]. This raises important questions. Although concerns about skin quality and aging have always been relevant in aesthetic medicine, the pandemic may have amplified these anxieties and potentially altered the relative importance of various motivators for seeking treatment [10-14].

To address this gap, this study aimed to examine the motivations and psychological impact of patients undergoing minimally invasive cosmetic treatments by analyzing data from 147 patients treated at Acquisition Aesthetics, a leading training academy in aesthetic medicine in the United Kingdom. Examining the perspectives of these patients can shed light on the complex motivations and perceptions that shaped their decisions in the wake of COVID-19. Ultimately, this knowledge can empower clinicians to deliver personalized care that truly aligns with the evolving needs of patients in the post-pandemic landscape.

This prospective observational study was conducted at Acquisition Aesthetics. Participants were recruited from among patients who attended Acquisition Aesthetics training courses as models across London, Manchester, and Newcastle. A self-administered questionnaire was distributed on iPads to all the participants, allowing real-time data entry and minimizing data transcription errors.

The questionnaire development process involved a comprehensive literature review to identify the key factors influencing patients’ motivations and perceptions regarding aesthetic treatments. Drawing on their collective expertise and understanding of patient needs, two highly experienced aesthetic clinicians and surgeons (PC and LW) formulated a questionnaire to assess a range of motives, outcomes, concerns, and feelings related to aesthetic treatments. This iterative process ensured the relevance, comprehensiveness, and alignment of the questionnaire with established research findings.

Respondents were asked to evaluate their reasons for seeking treatment, drivers for continuing treatment, desired outcomes they hoped to achieve, main concerns about undergoing treatment, post-treatment feelings, and the psychological impacts of skin aging. The survey employed a comprehensive approach that allowed the participants to select multiple options from a predefined list. The demographic information collected included age, sex, and history of aesthetic treatment. Data were analyzed using descriptive statistics. Composite scores were created to assess the level of concern or emphasis on various aspects of aesthetic treatment (Fig. 1-6). No inferential statistics were used as this study focused on exploring the range and nature of patient motivations and perceptions, rather than testing specific hypotheses.

Figure 1. The main instigators for having treatment. Respondents were allowed to select more than one option.

Figure 2. The main drivers to continue treatment. Respondents were allowed to select more than one option. F/F, friends and family.

Figure 3. The main desired outcomes of treatment. Respondents were allowed to select more than one option. F/F, friends and family.

Figure 4. The main concerns of having treatment. Respondents were allowed to select more than one option. F/F, friends and family.

Figure 5. The psychological impact of skin aging. Respondents were allowed to select more than one option.

Figure 6. The effects of treatment. Respondents were allowed to select more than one option.

This study was conducted in accordance with the Declaration of Helsinki and standards for research involving human subjects. Participant confidentiality and privacy were maintained throughout the data collection process, and informed consent was obtained from all participants before participation. No personally identifying information was collected or stored. Ethical approval was waived for this study because it involved the use of a non-sensitive and completely anonymous educational survey.

In total, 147 participants completed the survey (response rate=71.36%). Patients’ ages ranged from 20 to 63 years (mean age=42 years). Most patients (97.3%; n=143) were women. The study was conducted between September 9 and November 26, 2023. Participants were recruited as models from among individuals who attended training days.

Main instigators for starting and continuing treatments

The most common reasons for initiating treatment were to “improve confidence” (66.7%; n=98) and address “concerns about ageing” (63.9%; n=94) (Fig. 1). Notably, these two motivators remained consistent as the main drivers for continuing treatment (Fig. 2), suggesting their enduring importance to patients. Interestingly, although physical appearance played a role, a deeper examination revealed that three of the top four initial motivators focused on internal well-being and emotions: improving confidence, feeling less self-conscious (52.4%; n=77), and feeling happy (38.8%; n=57).

Overall, there was an absence of external advice or life events as treatment instigators. None of the respondents selected the options of “advised by medical professional,” “newspaper/magazine advert,” “social media,” “TV show/film,” “divorce,” “upcoming wedding,” “new in job,” or “new partner” as motivators.

However, a subtle shift in motivators was observed over time. Although improving confidence and preventing aging remained paramount, the desire to “fit in with friends and families” (28.6%; n=42) and “look more attractive” (17.0%; n=25) became more prominent as drivers for continuing treatment. This may indicate a growing influence of social factors as the treatment journey progresses. Conversely, the desire to “feel happy about one’s appearance” decreased significantly from 39% as an initial motivator to 14% as a driver for treatment continuation, suggesting that although happiness is initially important, it may become less critical once the desired outcomes are achieved.

Main desired outcomes of treatment

Building on the primary motivator for treatment, the outcomes reported by the participants further emphasized the transformative impact of these interventions. The most frequently desired outcomes were increased confidence (63.9%; n=94), less self-consciousness (46.9%; n=69), and enhanced attractiveness (34.7%; n=51) (Fig. 3). These internally focused outcomes were sought after more than “fitting in amongst friends and family” (21.1%; n=31), suggesting a strong emphasis on personal well-being and self-perception. The options for “stand out from the crowd,” “look better on social media,” and “fitting in with people I have seen online/TV/film/magazine” were not selected.

Main concerns of having treatment

The patients’ main concerns (Fig. 4) (fear of treatments not meeting expectations [57.1%; n=84], “not looking like me” [42.9%; n=63], and appearing “fake” or “unnatural” [40.8%; n=60]) highlighted the importance of realism and authenticity in aesthetic interventions. Concerns about pain and costs were less significant, with no respondents selecting options related to either. It is crucial for practitioners to set realistic expectations, use techniques that enhance patients’ natural features, and avoid overtreatment. Addressing these concerns can help build trust and reassure patients about the integrity of their results.

Psychological impact of skin aging

In addition to examining patients’ concerns regarding treatments, we assessed the psychological effects of skin aging, given that it is a primary motivator for instigating and continuing treatments. The most frequently reported effects were feeling self-conscious (38.1%; n=56), experiencing increased anxiety or stress (21.8%; n=32), and a lack of confidence (21.8%; n=32) (Fig. 5). The unselected options were related to more extreme emotional responses such as anger and impact on social functionality and interpersonal relationships. These findings underscore the multifaceted nature of skin aging, highlighting the need to consider not only physical signs but also emotional and psychological dimensions.

Effects of treatment

The reported positive effects (increased confidence [63.3%; n=93], happiness with appearance [44.9%; n=66], and feeling less self-conscious [42.9%; n=63]) highlighted the transformative impact of aesthetic treatment on patients’ lives. These outcomes not only improved patients’ self-perception, but also influenced their social interactions and overall quality of life. Again, no respondents selected the options related to social media or fitting in with the people seen on the media. Healthcare providers should focus on holistic benefits when communicating the value of treatment and during post-treatment evaluation.

Existing literature reveals a multifaceted relationship between aesthetic procedures, perceived attractiveness, and well-being. Studies have demonstrated that individuals who undergo facial aesthetic procedures are often perceived as more youthful, healthy, and attractive [15-18]. This perceived attractiveness is not merely superficial, as it has been linked to improved psychosocial health, enhanced social interactions, and a heightened sense of overall quality of life [15-18].

The COVID-19 pandemic amplified this relationship. Patients reported increased concerns about specific skin-related issues such as wrinkles, eyebags, and dark spots [9], potentially exacerbated by increased self-scrutiny during virtual interactions. Moreover, the pandemic seems to have spurred a broader interest in aesthetic procedures, as evidenced by the rise in Google searches for terms like “acne” (potentially linked to mask-wearing) [19], and a significant increase in patients considering such treatments [5,6,8]. Patients often believe that changes to their physical appearance will improve their psychosocial well-being [20]. It has also been reported that external factors, such as pressure to look younger from society or family and friends, are known predictors of interest in cosmetic treatments [7,21].

Our findings corroborate and expand on existing research. As reported in other surveys, motivations extend beyond the desire for cosmetic improvements alone, encompassing a broader spectrum of psychosocial well-being concerns [3,22-24]. Research supports that patients with internal motivations for seeking cosmetic treatments have greater satisfaction in outcomes than those with external motivations [25]. In our survey, patients’ motivations, concerns, and desired outcomes were predominantly driven by personal emotional well-being rather than external factors.

The primary motivation identified in this survey was to improve confidence. Previous research has identified that body image dissatisfaction improves significantly six weeks after minimally invasive cosmetic injectable procedures [1]. Additionally, in a placebo-controlled study employing a Quality of Life Enjoyment and Satisfaction Questionnaire, botulinum toxin injections were associated with improvements in overall life satisfaction, contentment, and self-esteem at various follow-up points [26]. A statistically significant improvement in self-esteem has been reported at two-weeks post-botulinum toxin injection, although that result did not persist at the three month review [27]. These findings are further supported by validated instruments such as the FACE-Q, which has consistently demonstrated improvements in facial appearance satisfaction, psychological well-being, and age appraisal after minimally invasive cosmetic procedures [28-33].

The significance of preventing aging being a key motivator in our study aligns with the established understanding of the psychological impact of skin aging. Factors affecting skin quality include tone evenness, surface evenness, firmness, and glow [11]. Studies have shown a correlation between increased skin quality or radiance, increased self-esteem, and increased perceptions of one’s attractiveness, age, and health by the general population [10-12]. The primary motivators of increasing confidence and preventing aging remained stable over time, suggesting their enduring importance throughout the treatment journey.

However, our study also revealed a subtle shift toward social motivation as the treatment progressed. The desire to “fit in with friends and families” and “look more attractive” became more prominent, potentially reflecting a progression in priorities once initial psychological needs like feeling happier and less self-conscious were met. This shift aligns with the broader context of the COVID-19 pandemic, which likely intensified concerns about social acceptance and appearance owing to increased virtual interactions and heightened self-scrutiny [8,9]. Surprisingly, however, there was minimal emphasis on external influences and situational factors in our survey’s results.

The significant drop in “feeling happier about appearance” as a continued driver could be indicative of satisfaction with treatment results, reducing the need for this to be a driving force for further treatment. The dynamic nature of patient motivation underscores the importance of personalized and ongoing communication between clinicians and patients to ensure that treatments continue to align with evolving goals and expectations.

Furthermore, our study sheds light on the complex relationship between the desire for aesthetic improvement and fear of unnatural results. Although perceived attractiveness and youthfulness were important motivators, patients also expressed concerns about treatment not meeting expectations, altering their natural look, and appearing “fake” or “unnatural.” This emphasizes the need for clinicians to set realistic expectations, prioritize natural-looking results, and use techniques that enhance patients’ unique features [14,34-36].

Our findings suggest that the COVID-19 pandemic may have subtly influenced the relative importance of motivations for seeking aesthetic treatments. The observed shift toward social motivation as treatment progresses, coupled with the high prevalence of concerns about aging and the desire to improve confidence, could be linked to the pandemic’s impact on social interactions, self-perception, and heightened self-scrutiny. However, further research with direct comparisons of pre- and post-pandemic motivators is required to confirm this hypothesis.

Although this study provides valuable insights, it is important to acknowledge its limitations. The study sample, consisting of individuals who volunteered to be models for training purposes, may not be fully representative of the general population seeking aesthetic treatments. We did not include a pre-pandemic comparison group, making it difficult to definitively attribute the observed changes to the pandemic. The predominance of female participants (97%) limits the generalizability of findings across sexes, as research suggests differences in motivations and concerns between men and women seeking aesthetic treatments [7]. Additionally, although the flexible response format allowed for a nuanced understanding of patient motivations, it also complicated the quantification and comparison of factors. Future studies using more structured approaches could refine our understanding of the relative importance of each motivator. Finally, reliance on self-reported data may introduce potential biases that warrant consideration when interpreting the findings.

Overall, this study reaffirms the importance of a holistic approach in aesthetic medicine, recognizing that patient motivations extend beyond physical appearance to encompass psychological and social well-being. Although the COVID-19 pandemic may not have drastically altered the core motivations for seeking treatment, it likely influenced the nuances and relative importance of these motivations. By understanding and addressing these multifaceted concerns, clinicians can deliver patient-centered care that not only enhances physical appearance, but also nurtures psychological well-being and overall quality of life in the post-pandemic era.

The authors have nothing to disclose.