Introduction

According to the International Society of Aesthetic Plastic Surgery [1], Italy ranks seventh in the world for plastic surgery based on the total number of cosmetic procedures and eighth for number of breast augmentation interventions. The most prevalent cosmetic surgical procedure performed by plastic surgeons in the world is breast augmentation. Given these trends, the aim of the present study was to identify significant antecedents of women’s interest in breast cosmetic procedures in the Italian context, focusing on sociocultural factors and on specific aspects of the self.

Much research has established a link between sociocultural influences and consideration of cosmetic surgery [2–7]. Empirical findings suggest that mass media influence on body image can predict more positive attitudes toward cosmetic surgery [8, 9]. Some recent studies showed that perceived media pressures to achieve social body ideals are related to attitudes toward cosmetic surgery through the internalization of beauty standards [e.g., 4, 10, 11]. A recent study carried out in the Italian context showed that perceived media pressures and the internalization of esthetic ideals could predict not only general attitudes toward cosmetic surgery, but also specific interest in cosmetic procedures aimed at modifying one’s breast [12]. In addition, peer influence seems to be a significant antecedent of consideration of cosmetic surgery through the mediation of internalization [e.g., 4, 10]. Peer attributions about the importance of weight and shape for popularity [13] seem to be significantly associated with eating behaviors [14], consideration of cosmetic surgery [10], and specific breast surgical procedures [12], through the mediation of the internalization of societal ideals. The more people think that appearance is important to gain popularity among peers, the more they are likely to internalize societal beauty ideals, which in turn might influence their interest in cosmetic surgery and specific breast cosmetic procedures.

Not only sociocultural influence, but also individual variables, such as personality factors [15–17], have been examined as significant correlates of attitudes toward cosmetic surgery. Anyway, little is known about how specific aspects of the self can influence attitudes toward cosmetic surgical procedures. It may be the case that individuals who are more likely to conform to social norms for both dispositional and situational reasons are more motivated to undergo cosmetic surgery. Conversely, individuals who are less likely to regulate their behavior according to the social environment for dispositional or situational motives are less inclined to consider cosmetic surgery favorably. The aim of the present study was to establish how individual variables, such as self-monitoring and self-awareness, can contribute to women’s interest in breast cosmetic procedures, beyond some sociocultural factors such as perceived media pressures, peer attributions, and the internalization of esthetic ideals.

Self-monitoring

Self-monitoring can be defined as the ability to regulate one’s behavior in response to social situations [18]. According to Snyder [18], people can be divided into two categories: high and low self-monitors (see Table 1). Being related to social appearance, self-monitoring could predict the importance that individuals place on their body image.

Table 1 Self-monitoring
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Sullivan and Harnish [19] found that high self-monitors considered their physical appearance as more important and reported engaging in more behaviors directed toward their physical appearance, compared to low self-monitors. Von Soest, Kvalem, Skolleborg, and Roald [20] suggested that high self-monitoring individuals might be more likely to consider cosmetic surgery as a strategy to control their physical appearance if compared to low self-monitors. In line with their hypothesis, they found that women’s self-monitoring predicted the decision to undergo cosmetic surgery: those who decided to undertake some cosmetic procedures regulated their behavior more to situational cues and others’ perception than to inner attitudes. Conversely, according to Henderson-King and Henderson-King [21], self-monitoring should not be related to acceptance of cosmetic surgery; self-monitoring is typically meant to refer to mercurial aspects of social behavior, while cosmetic surgery leads to permanent, and not temporary, changes. For this reason, high self-monitoring individuals should not differ from low self-monitoring ones in their attitudes toward cosmetic surgery. In line with their hypothesis, Henderson-King and Henderson-King [21] did not find a significant correlation between individuals’ self-monitoring and their acceptance of cosmetic surgery.

In observing these inconsistent findings, it might be argued that self-monitoring could be related to acceptance of cosmetic surgery when these procedures lead to changes that are widely accepted across different social contexts; even though permanent, such changes could help individuals to gain a social image that is commonly approved. With respect to breast cosmetic surgery, it is reasonable to think that for women a firm breast is largely appreciated, independently of the specific audience or context taken into account. Such an esthetic ideal is then likely to be internalized. Consequently, individuals who are more willing to modify their aspect and behavior to conform to social requests might be more likely to internalize societal esthetic ideals and to consider this kind of cosmetic procedure favorably. In sum, when considering breast cosmetic procedures, a positive and significant correlation between self-monitoring, internalization of societal esthetic ideals and interest in this kind of procedure is expected.

Self-awareness

Individuals typically shift the focus of their attention from their environment to themselves and vice versa [22]. Self-focus, which is connected to an individual’s cognition and behavior, occurs when the center of one’s attention is the self. Notably, self-focus can be either dispositional and quite stable, which is defined as self-consciousness, or situational and transient, which is commonly identified as self-awareness. According to the objective self-awareness theory [22], which has been strongly supported [23], self-focus involves an automatic comparison of the self with an ideal or standard self. Negative affect and dissatisfaction with the self can arise as a consequence of perceived discrepancy between self and standards, which might motivate the avoidance of such an aversive state through the restoration of consistency. An attempt to reduce the discrepancy can be made by regulating the self or by regulating standards, which can lead to change in one’s attitudes or behaviors. The tendency to change the self to match a standard might depend on how an individual perceives it hard to attain the standard. Self-awareness is thus a major mechanism of self-control (Fig. 1).

Fig. 1
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The objective self-awareness theory

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Self-focus has two dimensions, namely private and public, while private self-awareness involves attentiveness to the inner self, public self-awareness is characterized by attentiveness to overt features of one’s self [24]. Individuals in a state of public self-awareness can experience some discomfort because they perceive that they are the object of others’ evaluation, which might motivate them to modify their behavior to meet the perceived expectations of others [24]. Some research has shown that individuals are more likely to yield to social norms when the salience of public self-aspects is increased [25].

To the best of our knowledge, situational self-focus has never been examined with regard to consideration of cosmetic surgery. It is our contention that self-awareness might be directly related to individuals’ interest in some cosmetic procedures. When people perceive that their appearance is the focus of others’ attention (high public self-awareness), they might experience greater body image concerns and be more likely to consider cosmetic surgery as a strategy to modify their appearance to achieve common standards. Conversely, when individuals are more focused on their inner feelings and beliefs (high private self-awareness), they might be less interested in cosmetic procedures aimed at modifying their appearance.

The Present Study

The aim of the present study was to analyze the role of perceived media pressures, peer attributions, the internalization of esthetic ideals, self-monitoring, and self-awareness on motivation to undergoing beast cosmetic surgery. The hypothesized model is presented in Fig. 2.

Fig. 2
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Hypothesized model of variables predicting interest in breast cosmetic surgery

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We hypothesized that perceived media pressures, peer attributions, and self-monitoring predicted women’s interest in breast cosmetic procedures via the internalization of esthetic ideals (Hypothesis 1). We expected also that self-awareness had a direct effect on the dependent variable; specifically, public self-awareness was hypothesized to be positively associated with breast cosmetic surgery, while private self-awareness was predicted to be negatively related to the dependent variable (Hypothesis 2).

Materials and Methods

Participants

Participants were 132 Italian women from the normal population. All women were of Caucasian descent and lived in Tuscany. Participants had a mean age of 33.62 years, which ranged from 19 to 66 years (SD = 13.72) and a mean self-reported BMI (Kg/m2) of 21.43 (SD = 3.22).

Measures

Pressures

The Pressures subscale of the Italian version [26] of the Sociocultural Attitudes Toward Appearance Questionnaire-3 (SATAQ-3) [27] was used to assess the subjective sense of feeling pressure from the media to modify one’s physical appearance. The scale is composed of seven items (e.g., “I’ve felt pressure from TV or magazines to lose weight”) rated on a 5-point Likert-like scale (1 = Definitively disagree to 5 = Definitively agree). Cronbach’s alpha for this scale was 0.97.

Peer Attributions

Peer attributions about the importance of weight and shape for popularity were measured through the Italian version [28] of the Peer Attribution Scale (PAS) [29]. The scale included four items (e.g., “My friends would like me more if I lost weight”) with a 5-point Likert-type response format (1 = False to 5 = True). Cronbach’s alpha for this scale was 0.76.

Internalization of Thin Ideals

The Internalization-General subscale of the Italian version [26] of the SATAQ-3 [27], that is a 9-item self-report instrument, was used to measure the incorporation of the media’s thin ideals into one’s self-identity. Items (e.g., “I would like my body to look like the bodies of people who are on TV”) are rated on a 5-point Likert-like scale (1 = Definitively disagree to 5 = Definitively agree). Cronbach’s alpha for this scale was 0.96.

Self-monitoring

An Italian version of the Ability to modify self-presentation subscale [30] of the Revised Self-monitoring Scale [31] was adopted to assess participants’ self-monitoring. The scale is composed of six items and assesses the ability of regulate one’s self-presentation in everyday life. Each item (e.g., “In social situations, I have the ability to alter my behavior if I feel that something else is called for”) yields a score from 1 (Certainly, always false) to 6 (Certainly, always true); high scores indicate high self-monitoring. In the present study, Cronbach’s alpha for this scale was 0.76.

Self-awareness

Self-awareness was measured through some items taken from the Situational self-awareness scale [24]. Private self-awareness was assessed through two items (e.g., “Right now, I am aware of my innermost thoughts”) measuring sensitivity to inner feeling and introspective behavior; the two items were significantly correlated (r = 0.40; p < 0.001). Public self-awareness was assessed through one item (i.e., “Right now, I am self-conscious about the way I look”) measuring awareness of one’s physical appearance and presentation. Items were rated on a 5-point Likert scale (1 = Definitively disagree to 5 = Definitively agree).

Breast Cosmetic Surgery

The interest in breast cosmetic procedures was assessed through the following two items [32] “Imagine that cost is not an issue, how interested would you be in undergoing breast lift (cosmetic surgery to make your breasts appear firmer and less droopy)?” and “Imagine that cost is not an issue, how interested would you be in undergoing breast augmentation surgery (cosmetic surgery to enlarge your breasts)?”. The two items were significantly correlated (r = 0.42; p < 0.001) and were rated on a 5-point Likert-like scale (1 = Not at all interested to 5 = Extremely interested).

Procedure

Participants were recruited from public places, such as libraries and study rooms using opportunistic sampling techniques. They were told that the study was on attitudes toward cosmetic surgery; they took part in the study on a voluntary basis, and no incentives were offered to them. All of the questionnaires were completed individually in the presence of the researcher. Participants were required to be at least 18 years old; no other exclusion criterion was employed. All the women who participated in the study provided informed consent prior to completing the questionnaire. After participants returned the questionnaire to the experimenter, they received additional information about the study if they asked for it. Responses were recorded anonymously, and no personal identifying data were recorded. Study procedures were designed in accordance with the American Psychological Association’s guidelines for the ethical treatment of human subjects and were approved by the Director of Department of Psychology of the University of Florence.

Data Analyses

Descriptive statistics for all the variables were calculated. Intercorrelations between BMI, age, and interest in breast cosmetic surgery were performed. Path analysis employing the AMOS software, Version 20, was used to test our research hypotheses. Parameter estimates were derived using the maximum likelihood procedure. All of the variables included in the model were observed variables. The closeness of fit between the theoretical model and the data was evaluated through various goodness of fit indices, which included the following the χ 2/df ratio, the comparative fit index (CFI), the root mean square error of approximation (RMSEA), and the standardized root mean square residual (SRMR). Fit is considered good if the χ 2/df is at or below 2, and CFI values greater than 0.95. RMSEA and SRMR values as high as 0.08 are considered acceptable [33]. Anyway, CFI values between 0.09 and 0.95, RMSEA values between 0.05 and 0.10, and SRMR values between 0.08 and 0.15 are considered acceptable for small samples [34].

Results

Descriptive statistics (means and standard deviations) are reported in Table 2.

Table 2 Means and standard deviations for all variables
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No significant intercorrelations emerged between BMI, age, and interest in breast cosmetic surgery. The effects of the analyzed variables were examined using path analysis. The model was tested with regard to our hypotheses. The final model is shown in Fig. 3 with the standardized regression coefficients. The tested model had a good fit with the data considering the small size of the sample (χ 2 = 19.76, p = 0.03; χ 2 /df = 1.98; RMSEA = 0.09; SRMR = 0.08; CFI = 0.96). The model explained the 20 % of the variance of the dependent variable.

Fig. 3
figure 3

Individual and sociocultural variables predicting interest in breast cosmetic surgery

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In line with hypothesis 1, peer attributions, perceived media pressures, and self-monitoring predicted women’s interest in breast cosmetic procedures via the internalization of esthetic ideals. Predictors were positively associated with the mediator and the dependent variable. Results of the bootstrapping procedure [35] showed that the indirect effect of peer attributions, perceived media pressures, and self-monitoring on breast cosmetic surgery through the mediation of internalization of esthetic ideals was significant, as zero was not included in the 95 % confidence interval (see Table 3).

Table 3 Standardized Indirect effects on breast cosmetic surgery through the internalization of thin ideals based on the bootstrapping procedure
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In accord with hypothesis 2, both private and public self-awareness had a direct effect on the dependent variable. Specifically, public self-awareness was positively associated with breast cosmetic surgery, while private self-awareness was negatively related to the dependent variable.

Discussion

This research is one of few analyzing how specific aspects of the self could influence women’s interest in cosmetic surgery. Specifically, the present study aimed to examine the role of self-monitoring and self-awareness on Italian women’s interest in breast cosmetic surgery. We supposed that these factors might contribute to women’s interest in breast cosmetic procedures, beyond some sociocultural factors such as perceived media pressures, peer attributions, and the internalization of esthetic ideals, the role of which has been established by previous research [e.g., 4, 10]. We hypothesized a positive relation between self-monitoring and interest in breast cosmetic surgery through the mediation of the internalization of esthetic ideals; moreover, interest in breast cosmetic surgery was hypothesized to be positively related to public self-awareness and negatively correlated with private self-awareness.

In line with previous findings [12], both perceived media pressures and peer attributions were found to influence women’s interest in cosmetic surgery through the mediation of the internalization of societal esthetic ideals. More interestingly, all the individual variables taken into account showed a significant relation to our participants’ interest in breast cosmetic procedures. In line with our prediction, self-monitoring was found to influence our dependent variable through the internalization of beauty ideals. These findings suggest that women who are more concerned with displaying appropriate behavior in social situations are also more likely to internalize societal ideals and to consider breast cosmetic surgery favorably. It seems that high self-monitors, who are more aware of the cues indicating culturally shared standards of physical appearance, such as a firm breast, may internalize this ideal and feel the desire to achieve it; as a consequence, high self-monitor women are more likely to develop positive attitudes toward breast cosmetic surgery procedures, seen as a strategy through which this esthetic standard can be reached.

Furthermore, our research findings showed that situational self-focus has a relevant role on women’s attitudes toward breast cosmetic surgery procedures. Specifically, private self-awareness had a negative direct relation with the outcome variable, which suggests that women are less likely to consider breast cosmetic surgery positively when they focus on inner aspects of the self, such as their thoughts and feelings. Conversely, public self-awareness had a positive and direct relation with the dependent variable; when women focus on overt features of the self, such as their physical appearance, their motivation to modify their behavior to achieve social expectations may increase, so that they are more likely to be interested in cosmetic surgery. Under such a condition, breast cosmetic surgery might be perceived as a strategy useful to modify one’s appearance to reduce the perceived discrepancy between the actual and the ideal self [22].

These findings contribute to the understanding of the reasons that trigger women interest in cosmetic surgery. Not only sociocultural influences contribute to the development of favorable attitudes toward cosmetic surgery, but also specific aspects of the self have a relevant role. Specifically, individuals who are more likely to conform to social norms are more motivated to consider breast cosmetic surgery favorably. Notably, such a tendency to conformism is not only determined by dispositional factors, such as self-monitoring, but also by situational and transient cues that can direct one’s self-focus.

These results have relevant practical implications. Psychological assessment of motivations underlying women’s interest in cosmetic surgery is highly desirable [36, 37] and recommended for understanding whether or not cosmetic surgery can really improve the negative perception that women have of their bodies [38]. To identify personal reasons that lead individuals to consider these interventions could be useful to evaluate if these procedures can have a real positive impact on women’s wellbeing and social relationships. As a matter of fact, cosmetic surgery not necessarily helps women to reduce their body dissatisfaction. It could be useful to assess women’s postoperative expectations to understand if patients are seeking cosmetic surgery for secondary gains and not for internal reasons [39]. More importantly, given that breast cosmetic surgery produces permanent body changes, it is really important to understand if women’s motivation to undergo these procedures is related to stable reasons or is determined by temporary elements. As a consequence, it might be beneficial to assess patients’ motivation for undergoing breast cosmetic surgery at least twice before the decision is made; this kind of assessment could help surgeons and patients themselves to understand if their interest in cosmetic procedures is steady and fixed. When cosmetic surgery appears unnecessary, surgeons might propose alternative strategies that could help women to improve their satisfaction, such as trying to focus more on their inner feelings and thoughts, rather than on their body and external appearance.

Despite its several strengths, this study has some limitations. First, this research adopted a correlational design, so that causal inferences cannot be made; experimental studies could be useful for determining whether breast cosmetic surgery attitudes could vary as a consequence of self-awareness manipulation. Second, given that our model accounted for the 20 % of the variance of our dependent variable, future research should investigate the role of other factors, such as social comparison, self-esteem, and coping strategies, as potential antecedents of the interest for breast cosmetic procedures. Third, our outcome variable addressed attitudes toward breast cosmetic surgery but not attitudes toward other types of procedures. Future studies could evaluate whether these findings can be generalized to others cosmetic interventions.

Conclusion

To the best of our knowledge, this study is the first one that examines situational self-focus with regard to consideration of cosmetic surgery. From a practical point of view, these findings could help plastic surgeons in their everyday practice, suggesting the importance of routine psychological assessment to establish whether women’s motivation to breast cosmetic procedures is related to stable reasons or is determined by temporary elements. Patients might not be able to independently evaluate and understand the long-term risks and benefits of cosmetic surgery, and they should be informed that individuals who pursue cosmetic surgery for purely external and temporal reasons might be at risk for poor psychological outcomes. Cosmetic surgeons should screen patients with interviews and short questionnaires to predict success or failure of cosmetic surgery and identify psychologically unsuitable patients. Surgeons might discuss with patients about their beliefs, feelings, and expectancies related to cosmetic surgery; they could ask patients if they worry a lot about how they look, if they focus much on their physical appearance, or if they feel compelled to conform to some esthetic ideals. Patients should be aware that it is impossible to control the feedback they will receive on their altered appearance. Moreover, if people look for cosmetic surgery to conform to social norms, they might be reminded that social norms might vary across time. If such an assessment reveals that cosmetic surgery is sought for internal and stable motivations, the patient will be more likely to be satisfied not only during the period immediately following surgery, but also over longer periods of time.