Introduction

Today, aesthetic surgeries have acquired significant importance as a reflection of modern body perception. The increase in societal prosperity has contributed to the widespread occurrence of such surgeries. According to the results of an international study conducted in 92 countries in 2015, the number of aesthetic operations was determined to be 12,055,418. Approximately 85.6% of these cases were women, while men constituted 14.4% [1]. Rhinoplasty is a cosmetic surgical operation performed to enhance nasal aesthetics without affecting or correcting impaired functions. Among cosmetic surgical procedures, nasal aesthetics rank first [2].

Individuals undergoing cosmetic surgery are not patients with physical health problems; psychological factors are among the major motivators for opting for surgery. Studies have focused on psychiatric disorders such as body dysmorphic disorder (BDD) and borderline personality disorder (BPD) [3, 4]. Similarly, psychological characteristics such as low self-esteem, negative body image, and perfectionism can be motivational sources for cosmetic surgery [5,6,7].

Personality refers to the "unique patterns of thoughts, feelings, and behaviors that distinguish an individual." It includes a variety of traits such as a person's values, beliefs, motivations, and emotional states, as well as how they interact with others and their environment in different situations. Personality is a complex concept shaped by both genetic and environmental factors [8, 9].

Over time, different theorists have tried to define personality from various perspectives. Some focus on specific aspects, while others attempt to provide a broader explanation of personality [9, 10].

A personality trait refers to a person's consistent way of thinking, feeling, and behaving across different situations [9]. Hans J. Eysenck, a prominent psychologist in the field of personality, developed a theory of personality traits known as the PEN theory, which includes three dimensions: neuroticism, extraversion, and psychoticism. These dimensions are believed to be influenced by biological and genetic factors and remain relatively stable throughout an individual's life [11]. Eysenck's theory suggests that an individual's ability to learn and adapt to their environment is affected by their inherited nervous system [9, 12, 13]

Neuroticism is defined as "a personality trait characterized by elevated negative emotionality and mood instability." Individuals who score high in neuroticism often experience negative emotions more frequently and with greater intensity than those with lower levels of neuroticism. Additionally, people with high neuroticism tend to be more reactive to stress and more prone to mental health issues [14].

Those with high neuroticism are more likely to feel worried, anxious, or depressed. Furthermore, dealing with stress and difficult situations can be more challenging for individuals with high levels of neuroticism [15].

Extraversion is described as "a personality trait characterized by sociability, assertiveness, and a tendency to actively seek out social interactions and experiences." Eysenck and Eysenck noted that individuals with high levels of extraversion are typically outgoing, confident, and energetic, and they often enjoy being the center of attention in social settings [14].

Psychoticism is defined as "a personality trait marked by a lack of empathy, impulsivity, and a tendency towards aggression." People who score high in psychoticism may be more inclined to exhibit anti-social behavior and may struggle with controlling their impulses and emotions [14].

There is a lack of sufficient studies evaluating personality traits before cosmetic surgeries [16, 17]. Zojaji et al. conducted a study involving thirty patients seeking rhinoplasty and thirty healthy controls, utilizing the Millon Clinical Multiaxial Inventory (MCMI-III) to assess participants' personality traits. They found that the number of individuals with narcissistic personality traits was significantly higher in the case group compared to the control group [16]. Qian et al. examined the relationship between personality traits and various cosmetic treatment areas in a study that included 426 patients, covering five treatment areas: body, eyes, facial region, nose, and skin. Personality traits were measured using the Eysenck Personality Questionnaire (EPQ). Among the 36 rhinoplasty patients included in the study, the neuroticism scores were found to be significantly higher [17]. However, we could not locate a specific publication where the EPQ was used exclusively for rhinoplasty patients. The EPQ evaluates personality across three main dimensions: neuroticism, extraversion, and psychoticism, which are known to be related to biological and genetic factors. The EPQ is recognized as a reliable and stable measure of personality traits. Furthermore, its successful application in cosmetic surgery patients influenced our decision to use the EPQ in our study.

Childhood traumas (CTs) are defined as experiences in childhood that cause emotional pain or distress, often resulting in long-term psychological and physical effects. These experiences may include major natural events, terrorism, migration, war, domestic violence, neglect, or abuse [18]. CTs are classified into physical abuse, emotional abuse, sexual abuse, emotional neglect, and physical neglect.

The lasting impact of childhood trauma on personality development is well-recognized. It is generally believed that early life experiences play a vital role in molding an individual's personality, affecting their thoughts, emotions, and behaviors well into adulthood [9].

Childhood trauma can have a long-lasting effect on personality development. Studies show that those who have experienced childhood trauma—such as physical or sexual abuse, emotional neglect, or exposure to violence—are more likely to develop traits associated with neuroticism. Neuroticism involves a tendency towards negative emotions, including anxiety, depression, and vulnerability [19, 20]. Additionally, these individuals might show lower levels of extroversion, which includes being outgoing and assertive. Furthermore, some research suggests a link between childhood trauma and an increased tendency towards psychoticism, characterized by aggression, rebelliousness, and impulsivity [20].

In the literature, the relationship between CTs and rhinoplasty has not been sufficiently explored. In a study conducted, 218 patients were included post-surgery; of these, 86% were cosmetic surgery patients, and 80% of them were rhinoplasty patients. The patients were asked about ten adverse childhood experiences (ACEs), and 79% reported experiencing at least one adverse childhood experience [21]. This indicates that while the impact of CTs on personality is relatively well-understood, its effect on the decision to undergo rhinoplasty is not clear.

In our study, we aimed to investigate the direct or indirect effects of CTs on the decision to undergo rhinoplasty through personality development using the model we constructed. In this context, we tested the following hypotheses: CTs directly affect the tendency to undergo rhinoplasty; CTs are associated with high levels of neuroticism, low extraversion, and high levels of psychoticism; high neuroticism, low extraversion, and high psychoticism levels increase the likelihood of undergoing rhinoplasty; CTs indirectly affect the likelihood of undergoing rhinoplasty through personality traits (neuroticism, extraversion, and psychoticism).

Method

Study Procedure and Participants

Our study was conducted between 15.04.2023 and 15.07.2023. All participants were administered the Personal Information Form, the Revised Short Form of the Eysenck Personality Questionnaire (EPQ-RSF), and the Childhood Trauma Questionnaire (CTQ). The surveys were created using Google Documents. An introductory note detailing the purpose of the study and assuring participants that their data would be kept confidential was provided. A consent section stating that participation was voluntary was included, and online consent was obtained from those who agreed to participate willingly. After securing informed consent, participants were able to proceed with completing the scales. This survey was distributed to all participants via WhatsApp Messenger, a free cross-platform messaging service owned by Facebook Inc. All stages of this study adhered to the principles of the Helsinki Declaration. The surveys were delivered to all participants via online platforms, and no face-to-face interviews were conducted with the participants. Participants from different regions of the country (Turkey) and various sociocultural levels were included in the study. A total of 256 individuals who agreed to participate in the study were included. Inclusion criteria for the study include individuals aged 18–65, those who voluntarily agree to participate in the study and complete the online consent form, individuals proficient in reading and writing Turkish, participants who complete the Personal Information Form, EPQ-RSF, and CTQ questionnaires in full, and individuals with access to online platforms such as WhatsApp Messenger and Google Documents. Exclusion criteria include individuals under the age of 18 or over the age of 65, those who do not voluntarily agree to participate or do not complete the online consent form, individuals not proficient in reading and writing Turkish, participants who fill out the Personal Information Form, EPQ-RSF, or CTQ questionnaires incompletely or incorrectly, individuals with severe physical or psychiatric disorders (e.g., active psychosis, severe depression, bipolar disorder) or acute medical conditions, and those without access to online platforms such as WhatsApp Messenger and Google Documents.

Data Collection Tools

The Personal Information Form: is a questionnaire prepared by the researchers to assess the sociodemographic characteristics (age, gender, marital status, income level, educational status, employment status, rhinoplasty status, alcohol use, smoking habits, and the presence of family members who have had rhinoplasty), and medical and psychiatric health of all the cases in the study.

Revised Short Form of the Eysenck Personality Questionnaire: This shortened version of the Eysenck Personality Questionnaire, designed for easier application, was developed by Francis et al. [22]. The Turkish adaptation of the scale was conducted by Karancı and colleagues [23]. The scale measures three dimensions of personality traits: extraversion, neuroticism, and psychoticism. Additionally, the scale includes a lie scale to prevent bias and enhance reliability. Higher scores on the sub-dimensions indicate a more intense presence of the corresponding personality trait.

Childhood Trauma Questionnaire: Developed by Bernstein et al., this assessment tool comprises 28 questions, including three items that measure the minimization of trauma [24]. The scale yields five subscale scores addressing childhood sexual, physical, emotional abuse, and emotional, physical neglect, as well as a total score combining these subscales. The Turkish adaptation and validation of the Turkish form were carried out by Şar and colleagues [25].

Statistical Analysis

All analyses used in the study were performed using the open-source software JAMOVI v2.3.26. The analysis of the study consisted of two parts. First, frequency tables and descriptive statistics of the demographic data of the participants were created. In the second part, a mediation model was used to examine the direct or indirect effects of the variables in the proposed model. The Bootstrapping technique with 10000 repetitions was chosen to minimize estimation error. In the model, the subscales of the CTQ were independent (exogenous), the status of undergoing rhinoplasty was dependent (endogenous), personality traits were mediators, and the presence of rhinoplasty in the family was a moderating variable. Results were interpreted at a 95% confidence level.

Results

Of the participants, 38.3% (n=98) were male, 61.7% (n=158) were female, 52% (n=133) were single, and 84.4% (n=216) had college or university-level education. 41.4% (n=106) of the participants had undergone rhinoplasty, 18% (n=46) were considering rhinoplasty, and 40.6% (n=104) were not considering it. Participants' ages ranged from 18 to 54 years, with an average age of 31.07±8.79 years. Sociodemographic data of the sample are presented in Table 1. Descriptive statistics of the scale scores are given in Table 2.

Table 1 Sociodemographic and clinical data for the whole sample
Full size table
Table 2 Descriptive statistics of the scale scores
Full size table

Using a mediation model, the mediating effects in the proposed model were calculated (Fig. 1). According to the established model, emotional abuse increases the likelihood of undergoing rhinoplasty by 5.4% through neuroticism. The presence of a family member who has undergone rhinoplasty does not affect this outcome, but if such a family member exists, the rate increases to 17.7% (p < 0.05). Physical neglect does not affect the decision for rhinoplasty through psychotism, but in the absence of a family member who has undergone rhinoplasty, physical neglect decreases the likelihood of rhinoplasty through psychotism by 4.7% (p < 0.05). Extraversion increases the likelihood of rhinoplasty by 24.4%. If there is a family member who has undergone rhinoplasty, this rate rises to 30.9%, but if there is no such family member, it decreases to 22.4% (p < 0.001). Neuroticism increases the likelihood of rhinoplasty by 16.3%. If there is a family member who has undergone rhinoplasty, this rate rises to 29.3% (p < 0.001), and the absence of such a family member does not influence this outcome. Psychotism increases the likelihood of rhinoplasty by 15.4%. The presence of a family member who has undergone rhinoplasty does not affect the decision, but if there is no such family member, the rate increases to 19.1% (p < 0.05). Physical neglect increases the likelihood of rhinoplasty by 17.9% (p < 0.05). The presence of a family member who has undergone rhinoplasty does not influence this, but if there is no such family member, the rate increases to 22% (p < 0.05). Relevant data are presented in the Appendix.

Fig. 1
figure 1

Mediation model

Full size image

Discussion

Currently, there is still no established consensus on assessing the psychological profiles of rhinoplasty patients during the preoperative period. [21]. Certainly It would be important to assess some characteristics of the patients' mental health and emotional state prior to surgery, including depression, anxiety, panic, and aggression. The findings of this study demonstrate that CTs and personality traits significantly influence the decision to undergo rhinoplasty. Emotional abuse was found to increase the tendency for rhinoplasty through the mediation of neuroticism, while physical neglect played a role in rhinoplasty decisions through psychoticism. Additionally, extraversion was directly associated with a higher likelihood of opting for rhinoplasty. These results highlight the complexity of psychological and familial factors underlying the inclination towards cosmetic surgery. CTs can negatively impact self-perception and body image, thereby triggering an interest in aesthetic procedures, while personality traits also serve as crucial determinants in this process. The data underscore the importance of comprehensive psychiatric evaluations for candidates considering aesthetic surgery.

Personality traits, rather than being seen as distinct categories, exist on a spectrum where common human characteristics vary in intensity. Everyone possesses specific personality traits that define who they are, but these traits typically do not interfere with normal functioning. However, when these traits become excessively pronounced, they can inhibit individuals from leading a full and satisfying life, potentially leading to what is considered a personality "disorder" rather than merely a "trait." In the context of cosmetic surgery, particularly rhinoplasty, these personality traits can significantly influence decision-making processes and outcomes.

Neuroticism represents “a personality trait marked by heightened negative emotionality and mood instability.” Individuals with high scores in neuroticism often encounter negative emotions more frequently and intensely compared to their counterparts with lower neuroticism levels. Moreover, those with elevated neuroticism may exhibit increased reactivity to stressors and a higher susceptibility to mental health issues [14]. Such individuals are more prone to feelings of worry, anxiety, or depression and may face greater challenges in coping with stress and adversity [15]. The findings of our study demonstrate that neuroticism significantly influences the decision to undergo rhinoplasty. Neuroticism, associated with depression, anxiety, and emotional instability, can affect individuals' body image and their inclination towards cosmetic surgery. Individuals high in neuroticism tend to experience dissatisfaction with their appearance, and this dissatisfaction may drive them to seek corrective measures through procedures like rhinoplasty [26]. Additionally, the heightened reactivity to stressors and susceptibility to mental health issues among those with high neuroticism levels can increase their demand for cosmetic interventions. Thus, neuroticism not only influences individuals' inclination towards cosmetic surgery but also shapes their experiences during the process and their responses to the outcomes [27].

Extraversion is characterized by "sociability, self-confidence, and a tendency to actively seek social interactions and experiences." According to Eysenck and Eysenck, individuals with high levels of extraversion are typically outgoing, confident, and energetic, often enjoying being the center of attention in social settings [14]. Our study's findings demonstrate that extraversion significantly influences the decision to undergo rhinoplasty. Specifically, individuals with high levels of extraversion are more likely to choose rhinoplasty, reflecting their desire to enhance their social presence and meet high self-expectations [28]. This suggests that extraversion plays a role as a motivational factor in aesthetic procedures. The desire for social affirmation and the need for self-expression may drive extraverted individuals to seek cosmetic interventions. Therefore, considering levels of extraversion in evaluating rhinoplasty candidates is crucial for both the success of the surgical process and the psychological well-being of the patients. Our findings indicate that extraversion directly affects the likelihood of opting for rhinoplasty, emphasizing its importance in the decision-making process for aesthetic surgery.

Psychoticism is defined as “a personality trait characterized by a lack of empathy, impulsivity, and a tendency towards aggression.” According to Eysenck and Eysenck, individuals with high levels of psychoticism may be more prone to anti-social behavior and may struggle with controlling their impulses and emotions [14]. Our study's findings reveal that psychoticism significantly influences the decision to undergo rhinoplasty. Specifically, individuals with high levels of psychoticism are more likely to pursue rhinoplasty, possibly due to their heightened impulsivity and dissatisfaction with their appearance [29]. This trait may drive individuals to seek cosmetic surgery as a means of immediate change or self-enhancement. The tendency towards aggression and a lack of empathy might also reflect a desire to alter one's appearance to meet personal or societal standards, despite potential social repercussions. Therefore, psychoticism plays a crucial role in shaping the decision to undergo aesthetic procedures.

Our study findings reveal that CTs significantly affect the decision to undergo rhinoplasty, both directly and through personality traits. Emotional abuse increases the likelihood of rhinoplasty through neuroticism, with this effect becoming more pronounced if a family member has also had the procedure. Physical neglect influences rhinoplasty decisions through psychoticism, with the impact varying depending on whether a family member has undergone rhinoplasty. Additionally, extraversion and neuroticism are strong predictors of rhinoplasty, and the presence of a family member who has had the procedure moderates these effects. These findings highlight the critical role of childhood trauma and personality traits in determining cosmetic surgery decisions.

Childhood trauma has a profound and enduring impact on personality development, influencing thoughts, emotions, and behaviors into adulthood [9]. Experiences such as physical or sexual abuse, emotional neglect, and exposure to violence are linked to increased neuroticism—characterized by heightened negative emotions, anxiety, and depression—as well as lower levels of extraversion. Additionally, childhood trauma may be associated with higher psychoticism, which includes traits such as aggression and impulsivity [19, 20]. Despite these established connections between childhood trauma and personality traits, the specific relationship between these traumas and the decision to undergo rhinoplasty remains underexplored. A study involving cosmetic surgery patients indicated a high prevalence of adverse childhood experiences, yet the direct effect of these traumas on the decision to opt for rhinoplasty has not been clearly defined in the literature.

The relationship between CTs and rhinoplasty has not been thoroughly examined in the existing literature. One study investigated the connection between facial plastic surgery and psychiatric disorders, including a significant proportion of patients who had undergone rhinoplasty. A notable percentage of these participants reported experiencing at least one type of ACEs [21]. Childhood abuse and neglect often trigger feelings of body-related shame, which can manifest in self-harm behaviors, obsessive tendencies, extreme dependencies, and conditions such as BDD in adulthood. These feelings of shame may drive individuals to seek cosmetic surgeries [30]. Our study observed that emotional abuse influences the decision to undergo rhinoplasty through neuroticism, while physical neglect affects the decision through psychoticism. Additionally, physical neglect directly impacts the likelihood of undergoing rhinoplasty. These findings provide a significant foundation for understanding the effects of childhood trauma on rhinoplasty decisions and highlight the need for further research in this area.

The evaluation of personality traits, childhood trauma, and the presence of family members who have undergone rhinoplasty is crucial for effectively managing the rhinoplasty process. Personality traits can directly impact patients' surgical decisions and postoperative satisfaction; for example, neurotic tendencies and psychotic traits can influence patients' choices and recovery processes. Childhood trauma can affect personality development and body image, increasing the likelihood of pursuing cosmetic procedures such as rhinoplasty. Additionally, having a family member who has undergone rhinoplasty can shape an individual’s aesthetic preferences and surgical decisions. Preoperative psychiatric evaluation provides significant benefits by identifying these personality traits, traumatic histories, and familial influences. This evaluation helps in understanding patients' motivations, expectations, and psychological states, allowing for a more personalized and effective surgical planning. It also aids in improving surgical outcomes and enhancing patient satisfaction by addressing potential psychological risk factors and preventing possible postoperative issues. Thus, psychiatric evaluation is a fundamental step for ensuring the success of the rhinoplasty process and maximizing patient satisfaction.

Limitations

Several key limitations must be acknowledged in this study. First, the cross-sectional nature of the study restricts the ability to infer causality; longitudinal designs in future research could provide insights into how these relationships evolve over time. Additionally, the reliance on self-report questionnaires introduces the risk of bias and may affect the accuracy of the data. Incorporating objective measures or corroborative reports from close contacts could enhance data reliability. This study did not account for cultural differences in perceptions of cosmetic surgery, which could influence the findings; including a more diverse sample from various cultural backgrounds would offer a more comprehensive understanding. The impact of different types of childhood trauma was not sufficiently differentiated, and a more nuanced analysis is needed to understand how each type uniquely affects rhinoplasty decisions. Broader psychosocial factors such as societal pressure, media influence, and peer relationships were not adequately explored but could also significantly impact the decision to undergo rhinoplasty. While the study provides valuable insights into psychological factors influencing rhinoplasty decisions, addressing limitations related to sample size, study design, and potential biases is crucial. Future research should also explore a more diverse and larger sample, consider cultural factors, and examine psychosocial influences to strengthen the robustness and generalizability of the findings.

Conclusion

This study examined the impact of childhood traumas and personality traits on rhinoplasty decisions. The results indicate that personality traits, particularly neuroticism, psychoticism, and extraversion, as well as childhood traumas such as emotional abuse and physical neglect, are significant factors influencing the decision to undergo rhinoplasty. These findings provide valuable insights into how personal and traumatic backgrounds shape rhinoplasty decisions. However, the cross-sectional nature of the study and reliance on self-reported data may limit the generalizability of the findings. Future research should employ longitudinal designs to explore causal relationships, include larger and culturally diverse samples, and consider psychosocial factors. Furthermore, more detailed recommendations on integrating these findings into clinical practice could enhance pre-surgical assessments and interventions. It is important to note that this is the first study investigating the influence of childhood traumas and personality traits on rhinoplasty decisions and should be considered a preliminary study. As such, it lays the groundwork for future research in this area and highlights the need for further exploration to validate and extend these findings.