Facial aesthetic minimally invasive procedure: More than just vanity, a social‐psychological approach

Due to the great importance of the face in social interaction, minimally invasive treatments can—besides their ability to rejuvenate and enhance beauty—also change the way facial impressions of a person are perceived. In recent literature, three main character traits (attractiveness, trustworthiness, and competence) and subdomains essential for facial perception were described.


| INTRODUC TI ON
The annually released statistic report of aesthetic trends and procedures in the US surveyed by The Aesthetic Society revealed that the number of soft tissue filler injections performed in 2021 was 1 857 339 representing an increase of 42% compared with 2020, whereas the number of neuromodulator procedures was 3 651 223, representing an increase by 40% compared with 2020. 1 A recent multicentric prospective observational study investigated the selfreported motivation of 511 aesthetic patients to undergo minimally invasive treatments and found that apart from desiring to look better physically, patients wanted to protect their health, improve their sense of psychological well-being, and increase their comfort and confidence in social situations. 2 This finding is novel and points to a new understanding of aesthetic treatments which unfortunately for the aesthetic patients are still perceived to be associated with vanity or psychopathology. [3][4][5][6][7] Looking at the WHO definition of health it is stated that "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" implying that health is a multi-dimensional status in which many factors come to play apart from being disease free. 8 Of those factors, the social aspect is increasingly important in our interconnected society, and research in psychology has produced a wealth of evidence indicating that individuals continuously make social decisions based on facial appearances. [9][10][11][12] It has been shown that people spontaneously and subconsciously receive a wide variety of information about other individuals, such as gender, identity, intentions, emotions, attractiveness, age, or ethnicity just by looking at other people's faces. [13][14][15] Such information has been additionally shown to influence daily life matters such as business and employment opportunities and voting and sentencing decisions ultimately affecting social interaction and consequently playing a role in each individual's health. [16][17][18][19][20][21] According to research in social psychology, the dimensions in which facial features can be clustered are the following major three: attractiveness, trustworthiness, and competence. [22][23][24] Observed faces differ between these three dimensions which are composed of individually different subdomains: Attractiveness captures characteristics such as someone's physical attractiveness, age, and health; trustworthiness captures characteristics of someone's warmth, honesty, and approachability; and competence captures impressions of someone's intelligence, dominance, and capability. [25][26][27][28][29][30] Understanding that the aesthetic medicine influences facial appearances and that facial appearance provides nonverbal, unconscious, immediate information to other people in the respective social group increases the importance and relevance of facial aesthetic treatments performed. Facial aesthetic treatments influence each patient's health by influencing social interactions and social well-being.
The objective of the present study is to investigate whether minimally invasive procedures truly influence the three overarching domains of facial information (attractiveness, trustworthiness, and competence) and their subdomains when evaluated by independent, objective observers and not through self-reporting of the treated patient. It is hoped that this study will increase the awareness behind minimally invasive facial procedures and enforce that aesthetic treatments are far more than just vanity but actually contribute to each patient's health when defined by the WHO criteria.

| Study design
This study was designed as a cross-sectional online survey-based investigation in which 393 volunteers without aesthetic background were tasked to rate standardized pre-and posttreatment images of 34 female patients treated for aesthetic purposes. The rating was based on the attribution of defined character traits to the females displayed in the images. Those traits were classified into three overarching domains (attractiveness, competence, and trustworthiness;

| Image capture
The displayed images were aligned in appearance following a concept termed Evaluation Facial First Impression (EFFI); herein the images of the 34 females were aligned in hairstyle, dress, and background. All images were frontal face captures in neutral facial expressions taken under equal and standardized conditions using a Canon EOS 750D camera (Canon, Tokyo, Japan), at a distance of 1.2 m, and using an Elinchrom B250 monolight soft box (Elinchrom LTD, Renens, Switzerland).

| Online survey
The participating 393 volunteers rated the images of the 34 females online via a self-created online survey on the Qualtrics XM platform (Seattle, WA, USA; Figure 1). Access to these data can be requested from the corresponding author.
Image display occurred following randomization and volunteers were not able to rate the pre-and the posttreatment images of the same patient in their rating session to avoid direct comparisons and hypothesis guessing. Volunteers were asked to rate the images based on the predefined 18 characteristics (see Table 2) following a 7-point Likert scale ranging from 1 (= strongly agree) to 7 (= strongly disagree). Answers were exported for further statistical analyses. All patients were treated following good clinical practice and standard of care at the institution treated. All patients provided signed informed consent for the use of their personal-and treatmentrelated data to be used for the purposes of this study.

| Statistical analysis
Principal component analysis (PCA) with orthogonal (varimax) rotation was calculated and the number of factors was identified based on the screen plot, the Kaiser criterion, and parallel analyses. 32 Differences between the ratings of the pre-vs. the posttreatment images following the 18 character traits, a paired Student t test was performed (

| Attractiveness, trustworthiness, and competence
The independence of the three character traits was confirmed in the run computational model with attractiveness explaining 19.2% of the variance, trustworthiness explaining 63.7% of the variance, and competence explaining 7.1% of the variance.
F I G U R E 1 Exemplary survey question for the rating of the subdomains healthy, attractive and young in an 54-year-old female.

F I G U R E 2
Bar graph shows the mean values and standard deviation for the rating of the three overarching character trait domains competence, attractiveness and trustworthiness, both pre-and posttreatment. Asterisks (*) indicate a statistically significant difference.
Despite being rated independently and unpaired in the same session, there was a highly statistically significant difference between pre-and the posttreatment images for attractiveness, trustworthiness, and competence revealing an increase in all three overarching domains independent of the conducted treatment with all ps < 0.001 ( Figure 2 and Table 1).

| The 15 individual subdomains
In all 15 individual subdomains (except one), a statistically significant change was observed with all increasing their rating levels with p < 0.01 (Figures 3-5

| Additional exploratory domains
Emotional stability and Liking increased significantly during the performed treatment with both p's < 0.001 ( Table 2)

| DISCUSS ION
This study demonstrates that using injectables in cosmetic surgery significantly alters the perception of a person's facial appearance.
Increases were obtained not only in the impressions of facial attractiveness but also in facial impressions of trustworthiness and competence. These findings, combined with the knowledge that facial impressions matter in all kinds of social interactions-from romantic relationships to the workplace-have important implications for cosmetic medicine. This study also delineates that the muchfeared claim that injectables increase the "fakeness" of the face is unfounded.
At this moment there is little awareness in cosmetic medicine of the role that facial impressions play in social interactions. This lack of awareness is exemplified by the absence of a vocabulary to refer to goals other than changes in beautification and rejuvenation after treatment. The mean age of the women in this study was 50 years, which reflects the common age group seeking cosmetic treatment.
These women generally appreciate that they cannot look like in their twenties again and many do not aspire so. Yet, beautification and rejuvenation are the most common objective physicians are aiming for at the moment. As cosmetic doctors are unaware of the potential to change impressions beyond beauty that may be more relevant to clients, so are the clients themselves.
This study finds support for the three-dimensional nature of facial impressions. 22 An important practical question is whether procedures in cosmetic medicine can target a specific face impression, say trustworthiness, without affecting the other two. Both limitations in human biology and medical techniques will be critical factors here. Although clients and physicians usually address specific anatomical entities, such as eyes, nose, and mouth, faces can only be seen as a single entity in which individual features fuse into unique combinations. [33][34][35][36] A recent study shows that faces can be modeled along different dimensions, but many facial features are correlated. Therefore, it seems virtually impossible to isolate unique effects of any single F I G U R E 3 Bar graph shows the mean values and standard deviation for the rating of the three subdomains of the overarching character trait domain attractiveness, both pre-and posttreatment. Asterisks (*) indicate a statistically significant difference.
filler injection strategy. 37 Moreover, it seems that the way we infer character traits from faces is not only determined by the physical appearance of a face but also by observer's lay beliefs regarding the personality of others. 38 Judgments about faces and character traits are made by the human mind in a holistic manner. [39][40][41][42] With so many factors involved, it will be a challenge to develop treatments that focus on one specific trait dimension.
But the division of appearances into the subdomains attractiveness, trustworthiness, and dominance as we have done in this paper, is new as far as we know. A limitation of the current study is the exclusive use of pictures of Caucasian-looking women. But given that they make up 90% of the patients who undergo cosmetic facial filler treatment this is not as problematic as it seems. 43 It is an open question whether our findings also generalize to women of other ethnicities or men and whether we can find evidence for a more differentiated pattern in the efficacy of the cosmetic filler treatments across both genders and ethnicities. Furthermore, we only showed pictures of faces with a neutral expression; however, research has found that emotional expressions also contribute to the impressions of attractiveness, trustworthiness, and competence. 44 Because it has been suggested that cosmetic facial filler treatments inhibit emotional expressiveness, 45 it is a question for future research whether these improvements in social impressions are robust across various emotional expressions.

| CON CLUS ION
In conclusion, changes in facial features by injectables produce sys-

ACK N OWLED G M ENTS
The authors would like to thank Prof. John Arlette (Calgary, Canada) for supporting this work.

CO N FLI C T O F I NTER E S T S TATEM ENT
The authors declared no potential conflict of interest with respect to the research, authorship, and publication of this article.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available upon request. Data contain photographs that cannot be shared publically.

E TH I C S S TATEM ENT
The study was approved by the ethics committee of the Vrije Universiteit Amsterdam (VCWE-2020-161) and written and informed consent was obtained from all volunteers prior to the inclusion into this study for the use of their research-related data.