Statistical Analysis

We organized the data in Microsoft Excel (Microsoft Corpo-ration) and later exported it to jamovi statistical software (the jamovi project, 2023), version 2.3.21. Initially, we per-formed a descriptive analysis, calculating means, standard deviations, absolute and relative frequencies, and performed normality tests.

To assess the association between self-esteem and the intention to undergo aesthetic plastic surgery, we applied binary logistic regression. The dependent variable was the intention to undergo aesthetic plastic surgery, considering a dichotomous response (in which yes = 1 and no = 0) to the question “Do you want to undergo an aesthetic (or another) plastic surgery?”.

The initial analysis of self-esteem used a simple model and the reversed Rosenberg Scale (in which higher values indi-cate lower self-esteem). Next, we constructed a multivariate regression including the following covariates: self-esteem, gender (male/female), age (mean values of age groups), weight (mean values of weight groups), perceived profes-sional benefit of surgery, desire to improve appearance, desire to look like digital influencers, and frequency of social media posts.

We converted categorical variables to binary format (yes = 1, no = 0). We expressed the ordinal variable referring to the frequency of social media posts based on the estimated mean number of posts assigned to each response range: rarely (0.25), once a week (1), 2 to 3 times a week (2.5), 4 to 5 times a week (5), and daily (7). This approach allowed the inclusion of the variable as a continuous predictor in the multivariate analysis, based on the estimated equivalence of self-reported frequency. For categorical variables with miss-ing data, we applied point imputations based on the mode or point deletion. For continuous variables derived from ranges (such as age and weight), we used the mean values of the respective categories. This approach allowed the inclusion of all 303 participants in the multivariate analysis. The signifi-cance level adopted was p < 0.05. We reported the coeffi-cients (β), p-values, and odds ratios (ORs) with their respective 95% confidence intervals (95%CIs). We assessed the goodness-of-fit of the multivariate model using McFad-den’s pseudo R² value. We evaluated the discriminatory capacity of the model using the receiver operating charac-teristic curve, calculating the area under the curve (AUC).

Sociodemographic Profile of Participants

We sent the questionnaire to 327 students and selected 303 students for the study after excluding 24 participants who did not meet the inclusion and statistical analysis criteria. ►Table 1 shows the sociodemographic profile of the 303 students included in the analysis. The sample was predominantly female (68.98%), with ages ranging from 21 to 25 years old (45.87%), and of white skin color (66.01%). More than half (52.81%) of the participants reported a family income > R$ 10,000.

Table 1 - Sociodemographic profile of medical students participating in the study (n = 303)

Assessment of Self-Esteem and its Relationship with the Intention to Undergo Aesthetic Plastic Surgery

Analysis of the (reversed) Rosenberg Self-Esteem Scale revealed that low self-esteem had a statistically significant relationship with a greater intention to undergo aesthetic plastic surgery. The simple model, which considers only self-esteem as a predictor variable, showed that lower levels of self-esteem (higher scores on the reversed scale) had an association with a greater propensity to undergo aesthetic surgical procedures (β = 0.097; p < 0.001) (►Fig. 1). Howev-er, the pseudo R² value (0.09) indicated that self-esteem alone explained only 9% of the variability in the decision to undergo plastic surgery.

Fig. 1 - Comparison of self-esteem scores between participants with and without intention to undergo aesthetic plastic surgery. We used the reversed version of the Rosenberg Self-Esteem Scale, in which higher scores indicate lower self-esteem. The group with surgical intention had significantly lower self-esteem (p < 0.001). Source: The authors.

Fig. 1 - Comparison of self-esteem scores between participants with and without intention to undergo aesthetic plastic surgery. We used the reversed version of the Rosenberg Self-Esteem Scale, in which higher scores indicate lower self-esteem. The group with surgical intention had significantly lower self-esteem (p < 0.001). Source: The authors.

When including covariates in the multivariate model, the intercept was negative and highly significant (β₀ = - 8.58; p < 0.001). This indicates that, in the absence of any predis-posing factors (such as gender, low self-esteem, age, and aesthetic or professional motivations), the intention to undergo plastic surgery would be extremely unlikely. How-ever, when adjusting for other variables, self-esteem main-tained a statistically significant association (β = 0.137; p < 0.001), confirming that subjects with lower self-esteem remain more likely to undergo plastic surgery, even after adjustments (►Fig. 2).

Fig. 2 - Forest plot of multiple logistic regression showing factors associated with intention to undergo aesthetic plastic surgery. Eight variables were included: gender, age, self-esteem (reversed scale), perceived professional benefit, desire to improve appearance, fre-quency of social media posts, desire to look like digital influencers, and body weight. The vertical dotted line represents an odds ratio (OR) value of 1 (no effect). Abbreviation: CI, confidence interval.

Fig. 2 - Forest plot of multiple logistic regression showing factors associated with intention to undergo aesthetic plastic surgery. Eight variables were included: gender, age, self-esteem (reversed scale), perceived professional benefit, desire to improve appearance, fre-quency of social media posts, desire to look like digital influencers, and body weight. The vertical dotted line represents an odds ratio (OR) value of 1 (no effect). Abbreviation: CI, confidence interval.

Main Predictors of Intention to Undergo Plastic Surgery

Multivariate analysis (►Table 2) identified female gender as one of the most relevant predictors of surgical intention (β = 2.01; p < 0.001), with women being ~ 7.5 times more likely to express this desire compared with men. Age also demonstrated a statistically significant effect (β = 0.113; p = 0.001), indicating that, with each additional year, the chance of desiring cosmetic surgery increases by ~ 12%. However, the interpretation of this finding should be made with caution, considering that the sample consisted predom-inantly of young university students (21-25 years old), which may influence the direction and magnitude of this effect. Regarding the perceived career benefits of surgery (β = 0.942; p = 0.011), participants who believed that sur-gery could bring professional advantages were 2.56 times more likely to want to undergo the procedure. The desire to improve aesthetic appearance was the most strongly associ-ated factor with the intention to undergo plastic surgery (β = 3.158; p < 0.001), with an OR of 23.5, indicating that subjects motivated by aesthetic concerns were very likely to express this desire. The frequency of social media posts also presented a significant association with surgical intention (β = 0.563; p = 0.012), suggesting that the greater the digital engagement (frequent photo posting), the higher the pro-pensity for aesthetic surgery. This finding may reflect the indirect influence of social media on self-image and public exposure of the body.

Table 2 - Multiple logistic regression of factors associated with intention to undergo aesthetic plastic surgery among medical students (n = 303)

Other Factors with Marginal or Nonsignificant Effect

On the other hand, the desire to have a body similar to that of digital influencers (β = - 0.078; p = 0.824) did not show a significant association with surgery intention, indicating that this variable may reflect other factors already adjusted for in the model, such as self-esteem or social media use. Moreover, body weight (β = 0.008; p = 0.664) did not have a statistically significant effect on the desire to undergo plastic surgery.

Predictive Strength of the Model

The multivariate model presented a substantially better fit than the simple model, with a pseudo R² value of 0.5. Furthermore, we evaluated the accuracy of the multivariate model using the ROC curve. The AUC value of 0.89 demon-strates excellent discriminatory capacity (►Fig. 3). This suggests that the main factors influencing the decision to undergo plastic surgery are external, including social expect-ations, gender pressures, age, and perceptions of personal and professional benefits.

Fig. 3 - Receiver operating characteristic (ROC) curve of the adjusted logistic regression model. The area under the curve (AUC = 0.89) indicates excellent predictive performance in identifying the inten-tion to undergo aesthetic plastic surgery. The dashed line represents a random model (with no discriminative power). Source: The authors.

Fig. 3 - Receiver operating characteristic (ROC) curve of the adjusted logistic regression model. The area under the curve (AUC = 0.89) indicates excellent predictive performance in identifying the inten-tion to undergo aesthetic plastic surgery. The dashed line represents a random model (with no discriminative power). Source: The authors.

Although low self-esteem is associated with a greater intention to undergo plastic surgery, its impact is less significant when compared with sociocultural factors. Ap-parently, the key influences for the decision to undergo cosmetic procedures are aesthetic-related social pressures, perceived professional benefits, and demographic aspects, such as gender and age. Future studies should investigate how various aspects of self-esteem and body dissatisfaction interact with these motivations, particularly in the context of social networks and the construction of body image in highly competitive careers.

Sociodemographic Profile of Participants

The data from the present study resemble the sociodemo-graphic profile reported by Filho et al.,⁹ who also found a predominance of women (92.3%), white subjects (63.5%), and an income between 4 and 10 minimum wages (28.8%). These findings are consistent with the study by Rassi et al.,¹⁰ which reported a predominantly female (97.6%) and white popula-tion (26.9%), with a mean age of 35.31 years old (n = 501), and a mean income of R$ 7,341.69. The primary difference between the studies lies in the age range of participants; we focused on medical students, whereas the other studies examined subjects who had already undergone plastic surgery.

Age and Gender Influence

Female gender was one of the factors most strongly associ-ated with surgical intention, with women being 7.5 times more likely to desire the procedure compared with men (β = 2.01; p < 0.001). This finding is in line with the literature, which indicates that women often adopt beauty standards and experience heightened social pressure to conform to aesthetic norms.^11,12

Age also demonstrated a statistically significant influence (β = 0.11; p = 0.001), with a 12% increase in surgical inten-tion for each additional year of age. However, this association should be interpreted with caution, since the sample was predominantly composed of young university students (21-25 years old). Studies suggest that, in this age group, media exposure and the impact of social media are particularly relevant factors.¹³ In contrast, in older subjects, the desire for rejuvenation may play a more prominent role.¹⁴

Self-Esteem and the Intention to Undergo Aesthetic Plastic Surgery

The results of our study indicate that the intention to undergo aesthetic plastic surgery is influenced by a combi-nation of psychological and social factors, with self-esteem playing a relevant, but not solely determining, role. This conclusion is corroborated by Aguiar et al.,¹⁵ who, in a qualitative study of women undergoing cosmetic proce-dures, observed that, although the surgery promoted an improvement in the perception of self-esteem, this was not the main motivation for it, reinforcing the idea that the surgical decision involves a broader context of social and individual expectations. Subjects with lower levels of self-esteem tend to have a greater intention to undergo cosmetic procedures (β = 0.13; p < 0.001), corroborating previous studies that highlight body dissatisfaction as an even stronger predictor than global self-esteem.^14,16

However, the isolated contribution of self-esteem to surgical intention was modest (pseudo R² = 0.05), which is in line with recent studies suggesting that internalization of beauty standards and dissatisfaction with specific body parts are more robust predictors of this desire.¹⁷

Furthermore, the present study is unique in that it ana-lyzed medical students, a group rarely investigated in re-search on surgical intention. Al-Bashaireh et al.¹⁸ found a strong association between negative body image and favor-able attitudes toward plastic surgery among female univer-sity students in the United Arab Emirates, suggesting that academic and cultural factors may influence perceptions of body image and the pursuit of cosmetic interventions.

Perception of Professional Benefits and Influence of Attractiveness

Another relevant finding was the perception that plastic surgery can bring professional benefits, which was associat-ed with a greater intention to undergo plastic surgery (β = 0.94; p = 0.011). The “beauty premium” concept sug-gests that attractive subjects are often seen as more compe-tent and enjoy better job market opportunities.¹⁹

This perception may be particularly relevant for medical students, whose careers involve high levels of public expo-sure and constant interaction with patients and colleagues. Furthermore, the desire for appearance improvement was the factor most strongly associated with plastic surgery intention (β = 3.15; p < 0.001), indicating that dissatisfaction with one’s own attractiveness is among the most robust predictors of this desire.¹¹

The Role of Social Media and Digital Influencers

A Brazilian study from Portela et al.²⁰ confirmed the influ-ence of social media on body image perception and intention to undergo plastic surgery. These authors revealed that 79.5% of medical students considered undergoing aesthetic proce-dures due to exposure to digital content. In our study, the frequency of social media posts was significantly associated with the intention to undergo plastic surgery (β = 0.563; p = 0.012), suggesting that students who post more frequent-ly are more likely to have surgical intentions. In contrast, the desire to look like digital influencers did not show a signifi-cant association (β = - 0.078; p = 0.824). This suggests that exposure behavior may be more determinant than the explicit idealization of digital aesthetics. These findings indicate that, despite the significance of the digital environ-ment, factors such as academic pressures and professional expectations may play a modulating role in the relationship between social media and surgical intention, especially among medical students. Still, it is worth considering that, as pointed out by Mironica et al.,²¹ chronic exposure to aesthetic content on social media can generate cumulative effects over time, gradually influencing the decision to undergo aesthetic interventions.

Study Limitations

As limitations, we highlight that the cross-sectional design adopted does not allow the establishment of causal relation-ships between the variables studied, confining the study to the identification of statistical associations. The sample, although large, is composed exclusively of students from a private institution in the state of Goiás, Brazil, with a predominance of high-income families, which may limit the generalization of the results to other academic popula-tions or sociocultural contexts. The primary outcome, the intention to pursue aesthetic plastic surgery, was based on self-reports, which may not reflect the participants’ actual future actions due to possible economic barriers, fluctuating opinions, or changing contexts. Furthermore, we did not include relevant psychosocial variables, such as localized body dissatisfaction, social comparison, or symptoms of body dysmorphic disorder, which can significantly impact the decision to undergo cosmetic procedures and deserve investigation in future studies.²²