This cross-sectional study uses web-based survey data to evaluate casual observers’ willingness to pay for increased attractiveness through rhinoplasty and to determine a monetary value for changes in attractiveness.
Key Points
Question
What is the monetary value of changes in attractiveness achieved through rhinoplasty, as perceived by society?
Findings
This cross-sectional survey of 228 casual observers, analyzed using multilevel, mixed-effects linear regression, revealed a significant association between the change in attractiveness from a rhinoplasty and its monetary value as perceived by society. A rhinoplasty was valued at $6123.75 for 1 standard deviation increase in attractiveness, and $9223.05 for 2 standard deviations increase in attractiveness.
Meaning
Contingent valuation, or willingness to pay, is a well-established economic concept that may be useful for the valuation of cosmetic facial procedures.
Abstract
Importance
Contingent valuation, or willingness to pay, is an established economic concept that has been applied in other areas of medicine and may be useful for understanding the economic forces that determine the cost of cosmetic procedures.
Objective
To determine the monetary value of changes in attractiveness achieved through rhinoplasty, as perceived by society.
Design, Setting, and Participants
Cross-sectional survey administered via public online forums to 228 casual observers.
Main Outcomes and Measures
Participants were shown preoperative and postoperative photographs of 12 patients who underwent cosmetic rhinoplasty and 4 patients who did not undergo any surgery. They were asked to rate (1) the change in overall attractiveness of the patients, and (2) the monetary value they would associate with these changes.
Results
Completed surveys were obtained from 228 casual observers; 144 were female (63.2%); median age, 25 years (median income bracket, $50 000-$75 000). Multilevel, mixed-effects, linear regression was used to characterize the association between monetary value and change in attractiveness. There was a significant association between the change in attractiveness from a rhinoplasty and its monetary value as perceived by society. The baseline value of a rhinoplasty without any change in attractiveness was $3769.98 (95% CI, $3541.59-$4007.10; P < .001). To increase 1 standard deviation in attractiveness was worth an additional $2353.77 (95% CI, $2197.57-$2512.81; P < .001), while increasing 2 standard deviations in attractiveness was worth an additional $5453.07 (95% CI, $5052.57-$5865.51; P < .001).
Conclusions and Relevance
There is a significant association between the societally perceived value of cosmetic rhinoplasty and the change in attractiveness after surgery. The average value of a rhinoplasty in our study approximates the actual average cost of cosmetic rhinoplasty, suggesting that willingness to pay may be a useful concept for studying the value of cosmetic procedures.
Level of Evidence
NA.
Introduction
Rhinoplasty is one of the most common cosmetic facial surgical procedures performed in the United States.1 Studies have demonstrated that cosmetic rhinoplasty can improve perceived attractiveness,2 decrease facial asymmetry,3 and decrease perceived age.4 Patients who have undergone rhinoplasty also report improved overall quality of life associated with their surgery.5
Despite these benefits, there has been little research on the monetary value of cosmetic rhinoplasty. The average cost of rhinoplasty, according to the American Society of Plastic Surgeons, is $5046 (not including anesthesia, operating room facilities, or other fees),6 although this number varies widely by geography and clinician. Furthermore, due to its elective nature, the cost of rhinoplasty is not subject to the same determining factors as other medical procedures. For instance, Alsarraf et al7 found that cosmetic facial plastic surgical procedures appear to function similarly to luxury goods on a supply and demand curve, with higher cost associated with increased rather than decreased demand.
Contingent valuation, also known as willingness to pay (WTP), is an economic concept that reflects the maximum amount that a person is willing to pay for a service. A growing body of medical literature uses WTP to study societal preferences and valuations of various health care services.8 Within the realm of facial plastic surgery, WTP has been used to study society’s perspective of the monetary value of surgically reconstructing facial defects.9 Measuring WTP from the perspective of society (ie, the casual observer) is especially relevant in facial plastic surgery because many patients pursue procedures in hopes of influencing how their faces will be perceived by others.10
In the present study, we used WTP as a measure of the monetary value of cosmetic rhinoplasty as viewed by a cohort of casual observers. Specifically, we examined the association between WTP and the perceived increase in attractiveness after rhinoplasty.
Methods
Participants
This study was approved by the Johns Hopkins University School of Medicine institutional review board. A web-based survey (Qualtrics; https://www.qualtrics.com) was posted on public access websites and used to recruit a sample of casual observers, as described previously.9 Participants were not compensated for their participation. Completed surveys were collected from 228 participants and included in the analysis.
Survey Instrument
Identical surveys were administered to each study participant. The survey consisted of demographic questions as well as inquiry on whether participants or their loved ones had undergone cosmetic nasal surgery in the past. The survey then showed photographs of 16 patients in random order. For each patient, frontal and profile photographs taken at 2 different times were included (Figure). Twelve of the 16 patients in the photographs had undergone cosmetic rhinoplasty, and the photographs showed their faces before and after surgery. The remaining 4 patients were controls, and the photographs showed their faces at 2 different time points without any surgical intervention. Participants were informed that some of the patients had undergone surgery, while some had not. Photographs were obtained from our facial plastic surgery image archive, which we searched to identify patients who had undergone cosmetic rhinoplasty and no other procedures during the time between the before and after photographs, as well as control patients who did not undergo any surgery. Postoperative rhinoplasty photographs were taken no less than 6 months after surgery. All patients had consented to have their photographs used in research studies, and all photographs were standardized for facial expression and lighting.
Figure. Patient Sample Photographs.
A, This patient shows about a ½-SD increase in attractiveness. B, This patient shows a nearly 0-SD increase in attractiveness.
For each patient, WTP was assessed by the participants with a monetary visual analog scale ranging from $0 to $40 000 US currency. All monetary results are reported in $US. Survey participants were asked how much they would value a nose surgery with results as shown in the photographs. Next, participants were asked to rate the change in attractiveness of the patient in the photographs on the right (later) compared with the left (earlier). This rating was based on a visual analog scale from 0 to 100, with 50 representing no change in attractiveness, a number less than 50 representing decreased attractiveness, and a number greater than 50 representing increased attractiveness.
Data Analysis
All analyses were conducted using Stata statistical analysis software (Stata 11.2 SE, Stata Corp). Univariate linear regression was used to examine the associations between WTP and demographic characteristics of the participants. Multilevel, mixed-effects, linear regression was used to characterize the association between WTP and change in attractiveness. This allowed us to account for differences in individual baselines of each study participant’s WTP. To fulfill the assumption of normality for our mixed-effects regression, as well as account for the nonlinearity of WTP as a function of attractiveness, we performed a Box-Cox transformation on WTP values before applying the regression model (λ = 0.3795024). Because this transformation can only be performed for nonzero numbers, we replaced all WTP values of $0 with a random value between $0 and $1 prior to transformation. Change in attractiveness was converted from a raw score on a scale of 0 to 100 to a normalized z score by subtracting the mean attractiveness score for all patients from each individual attractiveness score, and then dividing by the standard deviation (SD). An individual with the average change in attractiveness would therefore have a z score of 0, and an individual with a change in attractiveness 1 SD above the average would have a z score of 1. The resulting coefficients from our regression model were ultimately back-transformed to real-world values of US dollars, which we report below.
Results
Completed surveys were obtained from 228 casual observers. A summary of participant characteristics is provided in Table 1. There were more female (63.2%; n = 144) than male (36.8%; n = 84) participants. The majority of respondents self-identified as Caucasian or white (73.2%; n = 167). The median income bracket was $50 000 to $75 000. Of the 228 participants, 16 individuals (9.3%) had either a personal history or a loved one with a history of cosmetic nasal surgery. The median age of participants was 25 years.
Table 1. Demographic Characteristics of 228 Participants.
| Characteristic | No. (%) |
|---|---|
| Sex | |
| Male | 84 (36.8) |
| Female | 144 (63.2) |
| Race | |
| Asian/Pacific Islander | 30 (13.2) |
| Black | 5 (2.2) |
| White | 167 (73.2) |
| Hispanic | 12 (5.3) |
| Native American | 1 (0.4) |
| Other | 13 (5.7) |
| Level of education | |
| Less than high school | 12 (5.3) |
| High school graduate/GED | 16 (7.0) |
| Some college | 54 (23.7) |
| 2-y degree (associate’s degree) | 11 (4.8) |
| 4-y degree (BA/BS) | 93 (40.8) |
| Master’s degree | 24 (10.5) |
| Doctorate degree | 18 (7.9) |
| Income, $US | |
| <25 000 | 57 (25.0) |
| 25 000-50 000 | 48 (21.0) |
| 50 000-75 000 | 52 (22.8) |
| 75 000-100 000 | 25 (11.0) |
| 100 000-150 000 | 21 (9.2) |
| 150 000-200 000 | 12 (5.3) |
| >200 000 | 13 (5.7) |
| History of cosmetic nasal surgery | |
| Yes | 16 (9.3) |
| No | 157 (90.7) |
Abbreviation: GED, general education diploma.
Table 2 details the median WTP value and change in attractiveness on a 100-point scale (with 50 representing no change in attractiveness) for each of the 12 rhinoplasty patients and 4 control patients. Median WTP ranged from $2254 to $6949 for rhinoplasty patients and $231 to $702 for control patients. Median rated change in attractiveness ranged from 52 to 70 for rhinoplasty patients and remained at 50 (no change) for all 4 control patients. The mean (SD) increase in attractiveness was 8.7 (14.1) points. The Figure shows examples of patient photographs from our survey, representative of approximately ½-SD (Figure, A) and 0-SD (control; Figure, B) changes in attractiveness.
Table 2. Median WTP and Change in Attractiveness Rated by 228 Participants.
| Patient | Median WTP, $US | Median Change in Attractivenessa |
|---|---|---|
| Rhinoplasty 1 | 3265.00 | 55 |
| Rhinoplasty 2 | 5046.00 | 61 |
| Rhinoplasty 3 | 4023.00 | 56 |
| Rhinoplasty 4 | 3642.00 | 55 |
| Rhinoplasty 5 | 6069.00 | 66 |
| Rhinoplasty 6 | 4969.00 | 60 |
| Rhinoplasty 7 | 4482.00 | 59 |
| Rhinoplasty 8 | 2254.00 | 52 |
| Rhinoplasty 9 | 6949.50 | 70 |
| Rhinoplasty 10 | 5985.00 | 64 |
| Rhinoplasty 11 | 3314.00 | 55 |
| Rhinoplasty 12 | 5838.00 | 68 |
| Control 1 | 702.00 | 50 |
| Control 2 | 549.00 | 50 |
| Control 3 | 324.50 | 50 |
| Control 4 | 231.00 | 50 |
Abbreviation: WTP, willingness to pay.
Rated on a 100-point scale with 50 representing no change in attractiveness.
In our univariate linear regression analyses, there were no associations between mean WTP (average WTP across all 16 patient photograph sets) and age, sex, race, education, or income of participants.
Using a multilevel, mixed-effects, linear regression model, we found a significant association between WTP and change in attractiveness (Table 3 and Table 4). The baseline value of a rhinoplasty without any change in attractiveness was $3769.98 (95% CI, $3541.59-$4007.10; P < .001). To increase 1 SD in attractiveness was worth an additional $2353.77 (95% CI, $2197.57-$2512.81; P < .001), while increasing 2 SDs in attractiveness was worth an additional $5453.07 (95% CI, $5052.57-$5865.51; P < .001). This equates to a total value of $6123.75 for a 1-SD increase in attractiveness, and $9223.05 for a 2-SD increase in attractiveness. Because the average change in attractiveness rating for a patient who underwent rhinoplasty was 11.4 (0.81 SDs), the mean cost of rhinoplasty in our study was $5619.03 (95% CI, $5325.67-$5921.97; P < .001). There was a residual constant of $1179.06 in our regression model, which we attribute to bias.
Table 3. Results From Regression of Normalized Attractiveness and Rhinoplasty on Willingness to Pay.
| Regression Term | Coefficient (95% CI) | Standard Error | P Value |
|---|---|---|---|
| Attractiveness (normalized) | 12.12 (11.42-12.83) | 0.3594 | <.001 |
| Rhinoplasty | 21.39 (19.99-22.80) | 0.7170 | <.001 |
| Constant | 35.95 (32.87-39.04) | 1.5740 | <.001 |
Table 4. Estimates and Standard Errors of Random Effects Parameters.
| Random-Effects Parameters | Estimate (95% CI) | Standard Error |
|---|---|---|
| Standard deviation (participant level) | 21.92 (19.92-24.12) | 1.068 |
| Standard deviation (residual) | 17.32 (16.91-17.74) | 0.209 |
Discussion
In the present study, we demonstrate the application of contingent valuation, or WTP, to determine the value of changes in attractiveness after cosmetic rhinoplasty. To our knowledge, this is the first study to assess the value of a cosmetic procedure by this method. Based on our model, the mean change in attractiveness from rhinoplasty is associated with a value of $5619.03, which approximates the known average cost of cosmetic rhinoplasty in the United States ($5046, not including anesthesia, operating room facilities, or other fees).6 Additionally, the value of a rhinoplasty increases nonlinearly with incremental improvement in attractiveness.
Cosmetic rhinoplasties can vary considerably in cost, given their elective and out-of-pocket nature. Furthermore, there is little research available to provide a meaningful guide as to what constitutes an appropriate cost based on surgical outcomes. We believe that WTP is especially relevant to measuring the cost of cosmetic procedures because their success can be largely dependent on the perception of the patient and other observers; that is, 2 patients with similar outcomes as measured by objective criteria may feel very differently about their results. Patients who undergo cosmetic surgery often do so with the consideration of how they will be perceived by those around them,10 and likewise WTP relies on the perspective of the casual observer to assign value to the results of such surgeries. Moreover, unlike most medical services in which the cost of care is typically divided between the patient and the insurance provider, WTP in cosmetic surgery reflects the direct out-of-pocket expense, which is also the full cost of care.
In our model, WTP had a nonlinear relationship with the change in attractiveness after surgery. The value of increasing 1 SD of attractiveness was $2353.77, while the difference in value between increasing 1 vs 2 SDs in attractiveness was $3088.30. This is congruent with previous research, which showed a nonlinear relationship between WTP and severity of facial defects, whereby participants were willing to pay substantially more to correct defects of higher severity than would be predicted by a linear model.9 The present findings also agree with the research that suggests that cosmetic facial plastic procedures appear to function as luxury goods in terms of supply and demand: demand increases, rather than decreases, with price.7 The nonlinear increase in WTP with increased attractiveness may explain why individuals are willing to pay very high prices to undergo surgery by a particular surgeon. However, it remains unclear whether better surgical outcomes (ie, increased attractiveness) is truly the driving force behind this supply and demand phenomenon.
Limitations
The present study has several important limitations. First, because the questionnaire was distributed and administered on public access websites, there was inevitably selection bias in our cohort of participants, and as such we cannot generalize our valuation results to any other population. We were, however, able to recruit a large number of participants from a broad range of demographic backgrounds, and therefore are confident that we were able to faithfully demonstrate the concept of contingent valuation as it applies to cosmetic surgery.
Second, patient photographs in the questionnaire were always presented in chronological order, and participants were asked to assign a value to the change in appearance from the earlier photograph to the later one. This likely created confirmation bias that would have led to overestimation of our WTP values, and is also reflected by the residual constant of $1179.06 in our regression model. The value of this bias should be taken into account when considering the accuracy of our WTP estimates in reflecting the true value of cosmetic rhinoplasty. However, the median WTP values for our control patients, despite being greater than 0 (the intuitive value of no intervention), were considerably less than those in the rhinoplasty patients. Moreover, while this residual bias may influence the total WTP values for cosmetic rhinoplasty, it would have less impact on the differences in WTP observed for incremental increases in attractiveness.
Third, we recognize the dichotomy between evaluating one’s own appearance and that of another person, and that the value of a cosmetic intervention may be viewed very differently by the surgical patient vs a casual observer. Nevertheless, we believe that by measuring WTP through a plurality, we are able to better understand the value of cosmetic rhinoplasty as viewed by society.
Finally, the median age of our participants (25 years) was relatively young in comparison to the general population, and WTP values may have been higher in an older population with higher incomes. Our cohort, however, does represent the age decade in which the greatest number of rhinoplasties are performed: in 2016, 31% of all rhinoplasties were performed in patients aged 20 to 29 years.11
Conclusions
Contingent valuation, or willingness to pay, is a well-established economic concept that may be useful for the valuation of cosmetic facial procedures. In our model, the average value of rhinoplasty was $5619.03, which approximates the known average cost of cosmetic rhinoplasty in the United States. Furthermore, the value of rhinoplasty increased nonlinearly with increased change in attractiveness.
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