Global Insights Into Confidence and Self-Perception in Aesthetic Medicine: A 15-Country Survey Analysis

Abstract

Background

Nonsurgical aesthetic treatments have been found to improve patient confidence; however, the interplay between patient attitudes and aesthetic treatment expriences is not fully understood.

Objectives

The aim of this study was to further characterize the role of confidence and self-perception in the decision to pursue aesthetic treatments and in patient experience of outcomes.

Methods

A total of 15,155 adults from 15 countries were recruited to participate in a device-agnostic online survey. Qualified participants were adults 21 to 75 years of age who had an aesthetic treatment in the past 12 months or would consider one in the next 24 months.

Results

Respondents reported a mismatch between their inner self and outward appearance, which may influence self-perception and social interactions. Individuals viewed aesthetic treatments as more than appearance enhancements, and many considered aesthetic treatments to be acts of self-care and empowerment, integrating them into their regular beauty routines. The strongest influence on individuals’ self-image was close personal relationships, whereas societal norms and social media played a secondary role.

Conclusions

Results suggest that confidence derived through aesthetic treatments can shape self-perception and social well-being; moreover, the decision to obtain aesthetic treatment is not at odds with self-confidence and can be an empowering experience.

Level of Evidence: 5 (Therapeutic)

The demand for surgical and minimally invasive facial aesthetic procedures continues to grow, with a 5% increase in overall aesthetic procedures in 2023 compared with 2022.¹ Importantly, individuals are seeking out aesthetic procedures not just to improve their physical appearance but also to improve their social well-being and mental and emotional health.^2-4 Clinically, nonsurgical aesthetic treatments are known to improve the confidence of patients, and the importance of their impact on patient quality of life is recognized by regulatory bodies.⁵ In clinical studies, interviews and independently validated clinical tools such as the FACE-Q Aesthetics module can help in determining such improvements.^3,6-13 Beyond these improvements, multifaceted dimensions of social and psychological function, including feelings of positivity and self-acceptance, can be positively affected by aesthetic treatment.¹¹

However, there is little in the current literature showing, on a broad scale, that the link between aesthetic treatments and confidence is a reason that individuals seek these interventions. The Pillars of Confidence global study (Merz Aesthetics; Raleigh, NC) was a multinational, multigenerational study designed to evaluate patient perceptions of aesthetic treatments and the impact of aesthetic treatments on patient confidence. This study was the first of its kind to be performed on a global scale, across multiple generations, in a population of this size.^2-4,11,14-16 Although clinicians know, based on their own experience, that the impact of aesthetic treatments extends far beyond the physical, this study characterized confidence as a core outcome in aesthetic interventions. The patterns uncovered provide key insights into the decision-making process patients utilize when seeking aesthetic interventions and are of interest to clinicians as they may inform treatment discussions with patients and tailor individual treatment plans.

METHODS

The survey was developed as part of a collaboration between Merz Aesthetics and Ipsos Group S.A. (Paris, France) and was reviewed and further refined in collaboration with an expert panel, which included a behavioral psychologist and 6 industry experts familiar with aesthetics, including physicians, executives, and media and beauty industry influencers from each of the regions where the survey was distributed. Questions posed for the portion of the study described here are included in Supplemental Table 1.

This device-agnostic survey was distributed online September 23, 2024, through October 8, 2024. Study participants were recruited through Ipsos panel partners. The opportunity to participate was advertised on social media and podcasts, and participants who were part of the Ipsos database of qualified participants had to opt in to the panel. Thus, all study participants were at least somewhat active online. A representative subset of participants was then selected from this larger group to receive the survey based on inclusion criteria: Qualified respondents included in the study were adults (≥21 years of age) who had had an aesthetic treatment in the past 12 months or would consider a nonsurgical aesthetic treatment in the next 24 months.

A 2-step weighting approach was used for each country where data were collected. First, the demographics represented by survey clicks from (1) those who completed interviews, (2) those who did not pass the screening, and (3) those who qualified but did not complete the survey were weighted to reflect the demographics of the general population. Demographic features considered were gender, age, region, educational level, and household income. In the second step, the weighted frequencies determined in Step 1 were applied to those respondents who completed the survey and qualified for the study analysis (the target population) to develop weighting targets for 1000 completed interviews per country.

Respondents were not paid through direct monetary compensation but, rather, participated in a point-based system in which points could be redeemed for rewards. The study was conducted in adherence to the standards of ESOMAR and the International Chamber of Commerce/ESOMAR International Code on Market, Opinion and Social Research and Data Analytics. Institutional review board oversight was not required, and the study met all international research ethics standards for market research.

Study data were evaluated using descriptive statistical analysis. Participants were grouped by generation as Baby Boomers (60-75 years), Generation X (44-59 years), Millennials (28-43 years), and Gen Z (21-27 years).

RESULTS

Respondent Demographic Characteristics

A total of 37,924 adults from 15 countries were screened, of whom 15,155 (40%) qualified for study inclusion (Brazil [n = 1019], Canada [n = 1009], China [n = 1014], Colombia [n = 1010], Costa Rica [n = 1008], France [n = 1008], Germany [n = 1006], Italy [n = 1008], Mexico [n = 1009], South Korea [n = 1019], Spain [n = 1006], Thailand [n = 1010], United Arab Emirates [n = 1010], the United Kingdom [n = 1009], and the United States [n = 1010]). Of this population, 75% were female and 25% were male. Patient age ranged from 21 to 75 years: 14% were classified as Baby Boomers, 28% as Generation X, 43% as Millennials, and 14% as Gen Z. The median survey length was 14 min.

Of the 15,155 adults included in the study, 20% were current users of facial injectables, energy-based devices, and/or facial treatments for wrinkles, fine lines, and/or skin smoothing. Approximately half (48%) reported a previous aesthetic treatment, which was consistent across generations except for Baby Boomers, who were 9% less likely to have had an aesthetic treatment in the past. Of the 7290 respondents who reported receiving an aesthetic treatment in the past (48% of the study population), most (69%) had had a treatment within the previous 12 months, while the remaining 30% had had a procedure ≥12 months ago. The time since last aesthetic treatment was relatively similar among generations, but 36% of Baby Boomers who had had a previous aesthetic treatment reported that it was >24 months ago (compared with 6% for Gen Z, 11% for Millennials, and 22% for Generation X). Of the participants who had undergone an aesthetic treatment in the past 12 months, over half (58%) had had ≥2 types of treatments.

Perceptions of Self, Confidence, and Internal/External Beauty Standards

When asked to select statements that described themselves, respondents indicated that they had high levels of self-confidence, intentionality, and belief in their capacity to reach their goals (Supplemental Figure 1). Most reported a positive attitude toward themselves (62%) and a strong sense of self-identity (73%). Two-thirds or more of survey participants indicated that they “consistently present their authentic self across various social contexts” (68%) and were “intentional” regarding what they applied to their body (66%). Participants also reported high levels of perceived self-agency, with 64% reporting they believed they could achieve outcomes that were important to them and 61% saying they had high levels of confidence in their ability to succeed in endeavors they set their mind to. Overall, 74% of respondents endorsed the belief that developing self-confidence is essential for one's overall well-being (Supplemental Figure 1).

Participants generally had a high level of self-care, confidence, and perceived emotional resilience. Most respondents (≥72%) “strongly” or “somewhat agreed” that they made time for self-care and were confident in who they were. Almost two-thirds (64%) of respondents “strongly” or “somewhat agreed” that their appearance aligned with how they felt inside; however, nearly the same percentage (62%) reported being “very concerned” about their appearance (Supplemental Figure 2). When asked how confident they felt when they looked in the mirror, 54% of participants reported feeling “very” or “somewhat confident”; however, 20% reported that they felt “somewhat not” (16%) or “not at all” (4%) confident.

Most respondents (≥72%) reported a positive relationship with their body, reporting that they respected their body and were attentive to its needs, felt love for their body (61%), and appreciated the unique aspects of their body (59%). However, 56% reported feeling critical of their physical appearance, 42% reported struggling to accept imperfections, 37% indicated they did not like to analyze their appearance, and 37% were not “comfortable in their own skin,” a finding somewhat inconsistent with the confidence reported above. Notably, 23% of respondents stated that they were indifferent toward their physical appearance.

Participants were also asked questions about the impact of external factors and beauty standards on their self-perception. Approximately 52% of respondents strongly believed that beauty is subjective. Digital interactions appeared to play a role in self-awareness, with close to half (40%) reporting increased attention to their appearance because of video calls. Even so, only 30% of respondents indicated that media had influenced their self-perception of beauty, with greater influence reported by Gen Z participants (41%) than Baby Boomers (14%). Across the generations, 28% of participants reported comparing their appearance to others on social media, and 26% reported feeling pressured to conform to societal beauty norms. Predictably, comparison to social media was more common among Gen Z than Baby Boomers (42% vs 12%) as was feeling pressure to conform to societal beauty norms (36% vs 13%).

Partners/spouses/significant others exerted the strongest influence on respondents’ perception of themselves, with 52% of respondents rating partners/spouses/significant others as “very” or “extremely” influential. Healthcare professionals, including physicians and aestheticians, as well as friends and family, were “very” or “extremely” influential for 45% of participants. In contrast, digital and media influences were reported to be less dominant, with social media, comments on personal social media posts, pop culture figures, and media advertisements reported as “very” or “extremely” influential for 23% to 29% of participants. Respondents in the Baby Boomer generation were less likely than younger generations to report high levels of influence (Figure 1).

Figure 1.

Influences on self-perception by generation. Participants rated the level of influence of each category on their perception of themselves as “not at all influential,” “not too influential,” “somewhat influential,” “very influential,” or “extremely influential.” Values shown indicate the proportion of respondents who selected “extremely influential” or “very influential.”

The data reveal a complex relationship with aging: 67% of respondents reported they believed aging was a natural part of life, but 39% feared getting older, and only 21% were excited about getting older (excitement decreased as generations aged up, ranging from 27% for Gen Z to 14% for Baby Boomers). However, 51% of respondents reported feeling that they gained more autonomy with age. Respondents appeared to be concerned with perceptions around aging: 51% indicated they did not want to be perceived as older than they were, 46% were worried that their physical appearance would decline as they aged, and 41% worried that the beauty they had when they were younger would fade with age. Further, 33% indicated that they feared losing their sense of self as they aged, indicating a link between outward appearance and self-perception.

Attitudes Toward Aesthetic Treatments

Of the 15,155 adults included in the study, 20% were current users of aesthetic products or treatments, and 48% reported having received an aesthetic treatment in the past. When asked about future treatments, 42% of respondents “would definitely” and 56% “might” consider an aesthetic treatment in the next 24 months. Most individuals (83%) who had received a previous aesthetic treatment agreed that they used treatments to enhance their appearance. Participants reported having an aesthetic intervention to create a look inspired by how they felt inside (69%), to help them stay true to who they really were (65%), or as part of how they express themselves (62%). Across generations, the most commonly received interventions were treatments for wrinkles, fine lines, and smoothing skin (45%); facial fillers (32%); injectables for wrinkles and fine lines (31%); energy-based devices for skin tightening (25%); and microneedling (22%).

Aesthetic treatments had a substantial role in shaping self-perception and self-care practices (Figure 2). Survey respondents indicated that these treatments helped them reconnect with their younger selves (62%), experience a more positive self-image (60%), and achieve a more positive self-dialogue (60%). More than half (55%) agreed that aesthetic treatments were an important part of their self-care, and 41% incorporated them into their regular beauty routines. Notably, most respondents (79%) preferred natural-looking results.

Figure 2.

Perceptions of aesthetic treatments by generation. Participants rated their level of agreement with each statement as “strongly disagree,” “disagree,” “neither agree nor disagree,” “agree,” or “strongly agree.” Values shown indicate the proportion of respondents who selected “strongly agree” or “agree.”

Aesthetic treatments had a broad impact on individuals’ self-perception and social confidence (Supplemental Figure 3). Respondents “agreed” or “strongly agreed” that treatments influenced how they viewed themselves (72%) or “agreed” or “strongly agreed” that treatments had an impact on confidence in social situations (66%). Additionally, 62% agreed that aesthetic treatments affected how attractive others found them, and 60% stated that aesthetic treatments impacted their overall outlook on life. More than half of respondents agreed that aesthetic treatments affected their “willingness to engage socially” (57%) and “participate in activities that might call attention to their appearance” (56%). A slightly smaller proportion of participants agreed that “aesthetic treatments affected their ability to attract a new partner or relationship” (54%), “participate in physical activity” (53%), “connect with family and friends” (50%), or “perform in the workplace” (49%).

In this survey, individuals who had undergone aesthetic treatments reported positive emotional and psychological effects. A substantial majority (82%) reported that after getting an aesthetic treatment they were satisfied with the results. Many also felt a sense of “renewal,” agreeing that they felt “refreshed” (79%) and “rejuvenated” (77%). Additionally, aesthetic treatments contributed to a broader sense of well-being, as most participants reported feeling “empowered,” more “fulfilled,” or more “alive” after undergoing an aesthetic treatment. Other notable impacts included reports of feeling “powerful” (64%) and having a greater sense of control (68%; Figure 3).

Figure 3.

Impact of aesthetic treatments. Participants who had previously undergone aesthetic treatment were asked to rate their level of agreement with each statement for the phrase “After getting aesthetic treatments, I feel_______” as “strongly disagree,” “disagree,” “neither agree nor disagree,” “agree,” or “strongly agree.” Values shown indicate the proportion of respondents who selected “strongly agree” or “agree.”

DISCUSSION

Understanding the perception of self, as well as the motivations to seek aesthetic treatments, can inform patient-centered approaches that support confidence and psychological well-being. In this study, survey data reveal that patients experienced confidence and “personal empowerment” through aesthetic treatments, which were, in turn, associated with improved patient perception of self and social well-being. The survey findings highlight the intricate relationships between self-concept, emotional well-being, and appearance. Furthermore, the findings emphasize that aesthetic treatments can be more than superficial enhancements: Patients reported undergoing aesthetic interventions as part of their self-expression and to help align self-perception and outward appearance. Importantly, 64% of participants indicated they did not strongly feel that their outward appearance matched how they felt inside. Aesthetic treatments were considered by many of the survey participants to be acts of self-care and were integrated into regular beauty/well-being routines. As people sought treatments that aligned with their personal identity, they reported feeling “refreshed,” more “alive,” and confident in their daily lives. Together, these findings highlight the importance of integrating both aesthetic objectives and the individual patient's psychological drivers into the consultation process.

The study findings underscore the complex interplay between body satisfaction and aesthetic procedures. Sixty-two percent of respondents reported being very concerned about their appearance, suggesting some level of dissatisfaction or desire for enhancement despite a high level of self-confidence. Published literature suggests that although aesthetic procedures may improve body satisfaction for some patients, a substantial subgroup derives minimal benefit in this area. Appreciation of this dichotomy is important for practitioners of aesthetic medicine and underscores the need for individualized treatment planning based on the patient's goals, desires, and mindset, including referral for psychological care when appropriate.^14-18 These data also suggest that some tension exists between self-reported confidence and self-criticism, a dichotomy important to recognize in patients.

By understanding how confidence, identity, and self-perception influence treatment motivations, clinicians can develop more personalized plans that align with patients’ internal goals. This, in turn, facilitates delivery of treatments that enhance satisfaction, optimize outcomes, and reinforce trust in the therapeutic relationship. Participants were most influenced by those closest to them, including their significant other and their friends, as well as their physician or other healthcare professional. This finding highlights the importance of the aesthetic clinician in guiding patients but also illustrates the range of influences in patients’ lives (Figure 1).¹⁹ Although social media and pop culture influences certainly remain relevant, their relatively lower ranking suggests that direct interpersonal feedback—particularly from loved ones and trusted healthcare professionals—may be a stronger motivator for seeking aesthetic treatments. Notably, bias (eg, response bias, social desirability bias) may have influenced responses regarding the relatively lower influence of social media. The results may further be compounded by the multi-ethnic sample.^6-9,20,21

These data also support a nuanced perception of beauty and self-image and highlight the evolving role of digital and media influences on self-perception. Concerns about physical appearance, combined with the impact of media exposure and social comparison, may influence individuals to seek aesthetic treatments to enhance self-confidence, particularly among younger generations. Studies have shown increasing dissatisfaction with body parts and an increasing interest in both invasive and noninvasive aesthetic procedures, potentially driven at least in part by social media, findings that are supported by this study's results.^6-10,21 Critically, social media and pop culture influencers were identified as a key source of information about aesthetic treatments. This is an important finding, as information on aesthetic treatments from such sources is commonly incomplete and/or inaccurate.

Although approximately half (48%) of all respondents had had a previous aesthetic treatment, this proportion was markedly lower for the Baby Boomer generation (39%) than for the Gen Z (50%), Millennial (53%), and Generation X (44%) participants in this study. Younger generations were born into a world in which cosmetic treatments were no longer taboo; however, the increasing proportion of Baby Boomers seeking aesthetic treatments demonstrates rising interest in aesthetic procedures regardless of age.^1,22,23 The survey did not assess the reasons for this difference, but barriers are likely multifaceted. Notably, respondents belonging to younger generations (Gen Z and Millennials) were more likely to “agree” or “strongly agree” with positive statements about aesthetic treatments compared with those in older generations.

The American Society of Plastic Surgeons 2023 statistics revealed that people 40 to 54 years of age (Generation X and Elder Millennials) accounted for the majority of both surgical and minimally invasive procedures in the United States, although Elder Generation X and Young Baby Boomers (ages 55-75 years) dominated the facial procedures category.¹ However, in our study, which included participants from 15 countries, Baby Boomers were more likely than other generations not to have returned for an aesthetic procedure in the previous 24 months. This may indicate loss to follow-up among this age group or may simply reflect a longer history for Baby Boomers to have received an aesthetic procedure.

The global Pillars of Confidence survey study highlights the emotional and psychological impact of aging as well as some of the psychological drivers of the decision to undergo aesthetic procedures. Concerns about maintaining a youthful appearance and a desire to control age-related changes may motivate individuals to seek aesthetic treatments.^2,24-26 Given that fear and worry about aging are common, aesthetic practitioners have an opportunity to provide not only physical treatments but also reassurance and education about the aging process, helping patients align their external appearance with their internal sense of self.^27,28 Although the desire to slow aging processes may impact the decision to seek aesthetic treatments, these results demonstrate that a majority of those who do so wish to align their external appearance with their inner selves and that aesthetic procedures are deeply tied to self-expression and identity.^2,29

The survey data support the impact of aesthetic treatments on quality of life, with more than half of respondents who previously had an aesthetic treatment indicating that aesthetic interventions impacted their self-view (72%), willingness to interact with new people/relationships (57%), and general outlook on life (60%). These findings underscore the expanding role of aesthetic medicine beyond appearance enhancement, demonstrating its psychological, social, and even professional implications. The study supports reports of the positive impact of aesthetic treatments on psychosocial dimensions of health.^30-32 Previous work using the FACE-Q Aesthetics module, a validated psychometric instrument, has demonstrated significant improvements in patient-reported psychological and social functioning after minimally invasive aesthetic procedures.³³ Further, these survey data align with research linking improved self-confidence with increased social engagement and professional performance.^34,35

This research has some limitations. For example, no results were analyzed based on whether respondents had previous aesthetic treatments or according to other subcategorizations (eg, gender). Further, the study population comprised individuals across a wide age range in 15 countries. Although representation from each country was balanced, the impact of cultural differences and regional attitudes most certainly affected individual perceptions and feelings around aesthetic medicine. Additional analyses are needed to identify any nuances specific to certain regions, ages, or subpopulations, as well as any differences among regions.

Moreover, findings are based on self-reported survey data rather than on measures of clinical outcomes. As with all surveys, data collection methods can be prone to bias, and results should be interpreted accordingly. For example, this survey was advertised on social media and podcasts, necessitating some level of digital engagement and literacy as well as willingness to participate in an online survey. Thus, responses may be weighted toward individuals who spend time online. Importantly, we do not have information on patient behavior following the survey and so cannot differentiate between attitudes of patients who go on to receive aesthetic care vs those who do not, or if attitudes before receiving care could affect perceptions of or satisfaction with treatment outcomes.

CONCLUSIONS

This international survey-based study further characterizes the relationships between patient attitudes, aesthetic treatment decisions, and the effects of treatments, indicating that, across cultures, self-perception and confidence are key motivators for obtaining aesthetic treatments. Together, these results support the global integration of personalized, psychosocially informed approaches in aesthetic consultations to maximize patient satisfaction and outcomes.

Supplemental Material

This article contains supplemental material located online at https://doi.org/10.1093/asjof/ojag058.

Disclosures

Dr Humphrey is a speaker, consultant, and/or investigator for Allergan (an Abbvie company (North Chicago, IL), Caliway (New Taipei City, Taiwan), Galderma (Zug, Switzerland), L’Oréal (Hauts-de-Seine, France), Merz Aesthetics (Raleigh, NC), and Revance (Nashville, TN). Dr Hernández is a consultant, speaker, and investigator for Merz Aesthetics, Croma (Leobendorf, Austria), and Fillmed (Paris, France). Dr Montes has served as a consultant and clinical investigator for Allergan/AbbVie, Merz Aesthetics, and Galderma. Dr Park serves as a speaker and consultant for Merz Aesthetics. Dr Voropai is a paid consultant for Merz Aesthetics. Dr Warnell has served as a consultant for Ipsos (Paris, France).

Funding

This research, as well as funding for medical writing support, was funded by Merz Aesthetics (Raleigh, NC).